Initial Environmental Examination

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

INITIAL ENVIRONMENTAL EXAMINATION

April 2019

MON: Fourth Health Sector Development Second Additional Financing

Prepared by the Ministry of Health of Mongolia for the Asian Development Bank.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

CURRENCY EQUIVALENTS (as of 19 March 2019) Currency Unit – togrog (MNT) MNT1.00 = $0.00037 $1.00 = MNT2,632

ABBREVIATIONS

ADB – Asian Development Bank DI – Design Institute DIA – District Inspection Agency (Ulaanbaatar) DRA – Drug Regulatory Agency EA – Executing Agency ED – Environmental Department (cities and aimags) EIA – Environmental impact assessment EMC – Environmental Management Consultant EMP – Environmental Management Plan EMS – Environmental Monitoring Station FGP – Family group practice FHSDP – Fourth Health Sector Development Project GASI – General Agency for Specialized Inspection GIEC – Grant Implementation Environmental Consultant GDP – Gross Domestic Product GOM – Government of Mongolia GRM – Grievance Redress Mechanism HCF – Health care facilities HRD – Human resources development HSMP – Health Sector Master Plan HSUM – Health Sciences University of Mongolia IA – Implementing Agency IEE – Initial Environmental Examination LIEC – Loan Implementation Environmental Consultant MDG – Millennium Development Goals MOF – Ministry of Finance MET – Ministry of Environment and Tourism MOH – Ministry of Health MSWL – Ministry of Social Welfare and Labor NCB – National competitive bidding RP – Resettlement Plan PHC – Primary health care PIU – Project implementation unit PMO – Project Management Office PPMS – Project performance monitoring system PSC – Project steering committee SHC – Soum health center SPS – Safeguard Policy Statement SS – Suspended Solids THSDP – Third Health Sector Development Project WHO – World Health Organization

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

WEIGHTS AND MEASURES

dB(A) – decibel (weighted average) ha – hectare kg/d – kilogram per day km – kilometer km2 – square kilometer m – meter m2 – square meter m3 – cubic meter m3/d – cubic meters per day m3/s – cubic meters per second mg/m3 – milligrams per cubic meter mm – millimeter

GLOSSARY

aimag – administrative unit (province) bagh – administrative unit (village) feldsher – community-based health nurse providing services in the bagh soum – administrative subunit of the aimag/province (district)

NOTE In this report, "$" refers to US dollars.

This initial environmental examination 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. Your attention is directed to the “terms of use” section of this website.

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.

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Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Contents

1. EXECUTIVE SUMMARY ...... 7 2. INTRODUCTION ...... 12 2.1. Introduction and Purpose ...... 12 2.2. Environmental Categorization, ADB and MON Approval of IEE ...... 14 2.3. Structure of this IEE Report ...... 15 3. POLICY, LEGAL, AND ADMINISTRATIVE FRAMEWORK ...... 16 3.1. Mongolia’s Environmental Policy ...... 16 3.2. Environmental Assessment Requirements ...... 20 3.2.1. Environmental Assessment Requirements of ADB ...... 20 3.2.2. Environmental Assessment Requirements of Mongolia ...... 22 3.3. Other International Environmental Requirements ...... 23 3.4. Mongolia HCF Environmental Infrastructure...... 23 4. DESCRIPTION OF THE PROJECT ...... 24 4.1. Overview ...... 24 4.2. Component 1: Songinohairkhan District Hospital ...... 26 5. DESCRIPTION OF THE ENVIRONMENT (BASELINE DATA) ...... 35 5.1. Physical Environment ...... 35 5.2. Ecological Resources ...... 42 5.3. Socio-Economic Conditions ...... 42 5.4. Sensitive Receptors Within The Project’s Area Of Influence ...... 44 5.4.1. Songinokhairkhan Hospital ...... 44 6. ANALYSIS OF ALTERNATIVES ...... 46 7. ANTICIPATED ENVIRONMENTAL IMPACTS AND MITIGATION MEASURES ...... 46 7.1. Screening and Avoidance of Environmental Impacts ...... 46 7.2. Positive Impact and Environmental Benefits ...... 47 7.3. Environmental Impacts and Mitigation Measures During Construction ...... 47 7.3.1. Physical Impacts ...... 48 7.3.2. Biological Impacts ...... 51 7.3.3. Socio-economic Impacts ...... 51 7.4. Environmental Impacts and Mitigation Measures during Operation ...... 54 7.4.1. Component 1: Songinohairkhan District Hospital ...... 54 7.5. Unanticipated Impacts During Construction and Operation ...... 57 8. INFORMATION DISCLOSURE, CONSULTATION, AND PARTICIPATION ...... 57 8.1. Consultation and Participation During Project Preparation ...... 57 8.2. Public Consultation for the new Songinohairkhan Hospital Component ...... 57 8.3. Future Information Disclosure and Public Consultation Program ...... 59 9. GRIEVANCE REDRESS MECHANISM...... 60 9.1. Introduction ...... 60 9.2. Proposed GRM for MON: Fourth Health Sector Development Project – Second Additional Financing ...... 60 10. ENVIRONMENTAL MANAGEMENT PLAN ...... 64 11. CONCLUSIONS AND RECOMMENDATIONS ...... 64 11.1. Project Benefits ...... 64 11.2. Anticipated Impacts and Risks ...... 64 11.3. Overall Conclusions ...... 65 12. REFERENCES ...... 66 13. ANNEXES ...... 67 Annex 1. Environmental Management Plan ...... 67 Annex 2. Comparison of WB EHS for HCFs and MON: Fourth Health Sector Development Project – Second Additional Financing Components ...... 89 Annex 3. Management Principles For Handling And Removal Of Asbestos ...... 91 Annex 4. IEE - Project Design and Monitoring Framework Versus Positive/Negative Impacts .. 92 Annex 5. GRM related Forms ...... 95

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

List of Tables

Table 1. International Environmental Conventions Signed by Mongolia ...... 17 Table 2: Key Mongolian Environmental Legislation ...... 18 Table 3: Key Mongolian Orders, Regulations and Guidelines Related to Hospital Waste ...... 18 Table 4: Key Mongolian Orders, Regulations and Guidelines Related to Hazardous Waste ...... 19 Table 5: Key Mongolian Orders, Regulations and Guidelines Related to Hazardous and Toxic Chemicals ...... 19 Table 6: Key Mongolian Orders, Regulations and Guidelines Related to Water and Wastewater ... 20 Table 7: Proposed Hospital Design Parameters ...... 28 Table 8: Average Water Quality In The Selbe River In Ulaanbaatar (1998-2008) ...... 37 Table 9: Air Quality Measurements & Mongolian Standards 2018 ...... 39 Table 10: Noise Measurements dB ...... 40 Table 11: Generation of Wastes from Songinohairkhan Hospital ...... 56 Table 12: Description of Participants in Hospital Public Involvement Program ...... 58 Table 13: Environmental Responsibilities by Project Phase ...... 69 Table 14: Summary of Potential Impacts ...... 71 Table 15: Environmental Monitoring Program for Songinohairkhan District Hospital ...... 82 Table 16: Environmental Monitoring Program for Central Laboratory ...... 84 Table 17: Cost Estimates For The Environmental Management Plan...... 87

List of Figures

Figure 1: EIA Process in Mongolia ...... 22 Figure 2: Site Plan of Existing Songinohairkhan District Hospital ...... 27 Figure 3: Initial Site Plan of Proposed Hospital ...... Error! Bookmark not defined. Figure 4: Revised Site Planning for Access Road, Additional Parking Area, Medical Gas Storage and Generator Buildings ...... 32 Figure 5: Google Map - Songinohairkhan Hospital Site ...... 33 Figure 6: Proposed Water Supply Relocation Plan ...... 33 Figure 7: Proposed Sewerage Relocation Plan ...... 34 Figure 8: Proposed Heating System Relocation Plan ...... 34 Figure 9: Proposed Electrical System Relocation Plan ...... 35 Figure 10: Distribution of Permafrost Near Ulaanbaatar ...... 37 Figure 11: Air Quality and Noise Monitoring Stations in Ulaanbaatar ...... 38 Figure 12: Seismic Risks In Mongolia and the PRC ...... 41 Figure 13: Flood Prone Areas of Ulaanbaatar ...... 42 Figure 14: Songinohairkhan Hospital Affected Area Map ...... 45 Figure 15: Example Construction Zone Perimeter Fence ...... 49 Figure 16: Noise Impact Zones During Construction ...... 51 Figure 17: Project Implementation Organizational Structure ...... 67

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Medical Waste Treatment Facility

District Hospital

Area

Ulaanbaatar City Urban Master Plan and Fourth Health Sector Project Major Activities and Related Infrastructure

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

1. EXECUTIVE SUMMARY

1. The original project “MON: Fourth Health Sector Development Project” planned to establish a demonstration multifunctional general hospital in Songinohairkhan District of Ulaanbaatar by renovating and expanding the infrastructure, equipping the hospital, and introducing innovative management systems. On 29 November 2010, ADB approved a Grant 0236-MON: Fourth Health Sector Development Project. The total project cost was $18.15 million, financed by an ADF grant of $14 million; WHO co-financing of $450,000 and the GOM remaining $3.70 million. In March 2012, the government requested additional financing to establish a new demonstration multifunctional general hospital in Songinohairkhan district of Ulaanbaatar instead of renovating the existing district hospital under component 1 of Grant 0236-MON. Loan 2932-MON: Fourth Health Sector Development Project – Additional Financing was approved on 5 November 2012 financed by an ADF loan of $22.68 million and a government contribution of $2.0 million. The loan agreement become effective on 14 June 2013 with current closing date on 31 December 2020.

2. The ongoing project (Grant 0236 and Loan 2932-MON) is performing well as it meets all the criteria including the review of safeguards compliance. The project has no safeguards policy compliance issues and safeguard covenant items are being complied. The component 1 is completed except the construction of the Songinohairkhan District Hospital (SDH), component 2 is 95% completed, and component 3 was fully completed in 2015. The overall progress in establishing the SDH is estimated at 55% as of October 2018.

3. The original project and first additional financing were categorized B for environment and C for indigenous people and involuntary resettlement as per ADB’s Safeguard Policy Statement, 2009. The Initial Environmental Examination (IEE) and the Environmental Management Plan (EMP) was revised to address the environmental implications of the new Songinohairkhan demonstration hospital and approved by ADB in August 2012. A Detailed Environmental Impact Assessment was conducted in compliance with the Mongolian Law on EIA and approved by Ministry of Environment and Tourism (MET) in Mongolia in August 2012.

4. On 16 November 2018, the government requested second additional financing to complete the SDH to address cost overruns caused by government requirements and regulatory changes introduced for implementation of the ongoing project. The proposed additional financing does not involve any scaling-up of the current design of the SDH. The second additional financing is estimated to cost $16.16 million. The overall project is estimated to cost $58.99 million.

5. This IEE is updated to reflect changes proposed under MON: Fourth Health Sector Development Project – Second Additional Financing. The second additional financing will be used to cover cost overrun to complete the Songinohairkhan hospital, relocating car parking area about 25m to west of the originally planned site, building a second access road around the existing hospital to ensure proper site access and construction of two additional buildings for medical gas storage (49m2) and generators (40m2) within the hospital site.

6. The design of a parking area and an access road was initially planned to be built in the location of the old hospital after its demolishment. The government objects to the deconstruction of the existing hospital due to the shortages of overall health services supply in the district of Songinohairkhan. Ministry of Health submitted a plan for old hospital to Municipality on 01 March, 2019. Existing hospital will be used for long-term care, palliative and rehabilitation services with a total capacity of 160 beds.

7. The SDH is connected with the Ulaanbaatar central electrical grid system. A backup electrical supply in the case of emergency is planned for the new hospital. The medical gases and generators as additional source of electricity were designed to be placed in the ground floor of the new hospital. However, the General Agency for State Inspection required to relocate them in two separate buildings outside the hospital. 7

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

8. The proposed additional financing will be implemented in 18 months from July 2019 to 31 December 2020 within the duration of the ongoing project. The implementation arrangements (i) executing agency; (ii) implementing agencies; and (iii) Project Implementation Unit (PIU) will remain unchanged from the ongoing project. Vamed Engineering GmbH, the construction contractor; and Ulaanbaatar City Investment Department and Junglim Architecture Co.,Ltd the construction supervisors under the ongoing project, will continue their respective roles under the overall project.

9. The primary focus of initial IEE for the G0236-MON: FHSDP was on rehabilitation and conversion of existing SDH to demonstration hospital under Component 1 and construction of new Central laboratory under Component 3. The IEE concluded that environmental impacts are minor and some risks related to waste management during development of SDH and the Central laboratory. The IEE was revised in 2012 to address changes of project configuration that the SDH will be replaced with a completely new hospital and demolish old hospital building. The initial IEE was fully updated integrating necessary mitigation measures to implement during the construction of the new hospital building. This update provides an assessment of potential environmental impacts and risks associated with the proposed changes of MON: Fourth Health Sector Development Project – Second Additional Financing components and other project components and covers the entire project. It includes (i) a summary of the local, national, and international policies, standards, and guidelines; (ii) due diligence review of the New SDH detailed environmental impact assessment (EIA) undertaken to meet Mongolia environmental regulations; (iii) description of the project and anticipated environmental impacts and mitigation measures; (iv) information disclosure, consultation and participation; (vi) grievance redress mechanism; and (vii) a detailed EMP, including implementation schedule and performance indicators.

10. Impact and outcome. The impact, outcome and outputs of the overall project will remain unchanged from the ongoing project. The impact of the project will be improved health status of Mongolians. The outcome will be improved health sector efficiency, governance and drug safety. The project geographic focus is in Ulaanbaatar, but the improvements will have benefits for the entire country.

11. Under this overall structure, the MON: Fourth Health Sector Development Project – Second Additional Financing will have three components with the following outputs:

a. Component 1: Strengthened Hospital Services in Ulaanbaatar. As part of reforming the hospital sector, the overall project has assisted the government in preparing a hospital development policy and strategic plan for Ulaanbaatar, it has operationalized a hospital capital planning system and improved the hospital governance system. The additional financing will assist in establishing a demonstration multifunction general hospital in Songinohairkhan district. b. Component 2: Strengthened Human Resource Development. The Project supported developing a hospital management module and including it among the programs offered by a local training institution. The outputs under this component have already been completed under the overall project. c. Component 3: Strengthened Drug Safety Regime. This overall project has established a drug regulatory authority, strengthened drug regulatory functions, upgraded the drug control laboratory to international standards, upgraded the standards of good manufacturing processes for drugs, strengthened drug post- marketing surveillance and adverse drug reaction, and improved drug safety governance functions of the Ministry of Health (MOH). The outputs under this component have already been completed under the overall project.

12. Safeguards. Environmental categorization for the first additional financing is B. Indigenous peoples and involuntary resettlement categories are C, the same as the original project according to ADB’s Safeguard Policy Statement 2009. For second additional financing, 8

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

indigenous people category is C and environment and involuntary resettlement categories are B due to the expansion of a parking space and a hospital access, which requires resettlements of households. The government will be responsible for the resettlement of the households in accordance with the ADB Safeguard Policy Statement, 2009.

13. The project complies with domestic environment safeguards requirements. A formal request was submitted by the EA to the Ministry of Environment and Tourism (MET) to conduct a General EIA (screening) for both major components, in accordance with the Mongolian Law on Environmental Impact Assessment (1998, amended in 2002). For the Songinohairkhan District Hospital expansion, a General EIA was carried out by MET in 2010. MET required a detailed EIA at the local level for the new hospital, and MET the detailed EIA was approved in August 2012. The ADB equipment support to the new Central Laboratory required an EIA at the local level (approved in 2010), since the entire laboratory building had not received a local environmental review previously. The ADB project supported the Drug Control Laboratory, which was a part of this new Central Laboratory project. The construction of the new Central Laboratory Building was completed in December 2012. The original IEE report was prepared in accordance with ADB’s Safeguard Policy Statement (2009), approved by the East Asia Regional Department (EARD) of ADB in October 2010 and disclosed on ADB’s project website. The IEE and EMP was revised to address proposed changes under the first additional financing and approved by EARD and disclosed on ADB’s project website on 24 August 2012.

14. The second additional financing will be used to cover cost overrun to complete the SDH, changing some sections of the hospital access road alignment, relocating parking area around 25m to west of the originally planned site and construction of additional buildings for medical gas storage and electricity generators. The parking area and access road was initially planned to be built in the location of old hospital after its demolishment. However, the old hospital will not be demolished as per EA request. Electricity generators and medical gases were planned to be placed in the ground floor of the new hospital. The General Agency for State Inspection required to relocate them in two separate building outside of the hospital. The two new buildings will be built within the hospital site.

15. The IEE provides an assessment of potential environmental impacts and risks associated with the proposed MON: Fourth Health Sector Development Project – Second Additional Financing components, and includes (i) a summary of the local, national, and international policies, standards, and guidelines; (ii) due diligence review of the major MON: Fourth Health Sector Development Project – Second Additional Financing component; (iii) description of the projects and anticipated environmental impacts and mitigation measures; (iv) information disclosure, consultation and participation; (vi) grievance redress mechanism; and (vii) a detailed EMP, including implementation schedule and performance indicators.

16. Potential impacts. As described above, the major infrastructure project with potential environmental impacts is the SDH construction under Component 1 and this infrastructure project is the primary focus of this IEE.

17. The principal impacts identified during screening related to the SDH will arise during construction. These are (i) increased traffic congestion near the project sites; (ii) increased noise and dust levels; (iii) the construction of new SDH building, access road around the old SDH building, relocating parking area and two additional buildings for medical gas storage and electricity generators; and (iv) occupational and community health and safety issues. These impacts are considered reversible and site specific and can easily be mitigated to acceptable levels through sound environmental management planning. The existing hospital will not be demolished; therefore, no asbestos handling is required.

18. The SDH is located in Ulaanbaatar city and ecological resources are limited. The project will not encroach on legally protected sites. The construction of SDH will be located in the existing Hospital campus, which has very little vegetation or exposed ground which may form habitats for fauna. There is a limited number of bird species observable in the city, such 9

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

as crows and sparrows, common to many urban environments. The project will not encroach on any physical or cultural resources.

19. During operations, the main potential impacts relate to the proper management of medical and hazardous wastes from the SDH and an access to the new SDH. On medical wastes, the new SDH will be equipped with an integrated waste management system in a detailed design in compliance with the 2011 MOH Orders 158 and 179 on health care facility waste management. In addition, the hospital is located very close to the Ulaanbaatar Central Medical Waste Treatment Facility at the Naran Enger Landfill, which is proposed for improvement under the ADB Fifth Health Sector Development Project. A transportation management plan will be prepared to address access issues to the new hospital.

20. Occupational health and safety issues may arise during construction. These risks will be mitigated through stringent site management controls. Contractors will be required to continue engaging an Environment, Health & Safety Officer (EHSO), ensuring that all reasonable steps are taken to protect any person on the site from health and safety risks. The construction sites will provide safe and healthy workplaces, and machinery and equipment will be kept safe and in good working order.

21. Environment management plan. An EMP was developed that identifies all mitigation measures required to protect the environment and public health and safety. The relevant aspects of the plan will be monitored during and after construction. The majority of the EMP monitoring will be undertaken by the Project Implementing Unit (PIU). The MON: Fourth Health Sector Development Project – Second Additional Financing PIU will continue to be responsible for ensuring implementation of the EMP and will undertake inspections as well as interview potentially affected people throughout project implementation. Environmental parameters are also included in the monitoring plan; air quality and noise will be monitored by a licensed laboratory to confirm the anticipated low impact of the project on the environment during construction, and positive impact during operation.

22. Consultation, participation and grievance redress mechanism. Public and agency consultation meetings were held in July 2012 in Ulaanbaatar for the SDH. Participants included a representative cross section of stakeholders including government officers, NGOs, academics and residents. This comprehensive consultation indicated that the majority of the affected people had a positive attitude toward the project and believed it would benefit them in the long term through shorter journey times, increased safety, and an improved local environment. A Grievance Redress Mechanism (GRM) has been established to address public complaints related to project activities during project implementation and operation. Consultation and participation will continue throughout project implementation and any environmental complaints or disputes will be handled in accordance with the GRM.

23. Public consultation near the proposed construction of new SDH was carried out on 19 June, 2012. The public consultation was held through interview and filling environmental questionnaires by community members living around the hospital area. Regarding the participants on the survey, 100% supported enhancement work of SDH. On 25-27 March 2019, household-level meetings were organized with support of the resettlement consultant. Residents who are either partially or totally affected by proposed road construction for SDH access, participated in the consultations. Interviewers were supportive of the road construction and they also stated that street lightning is needed. Additional individual and public meetings with affected persons shall be organized during development of the project design drawings to provide information about the ongoing project. Detailed information is included in the Land Acquisition and Resettlement Plan.

24. Project Benefits. The project will directly benefit over 320,000 mostly poor residents of the Songinohairkhan District of Ulaanbaatar by improving district hospital services. The project will also benefit the entire population of Mongolia by improving access to safer drugs, and in the long run, will improve allocative efficiency in the health sector by optimizing the use 10

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

of hospital services and improve return on future investment in the hospital sector. Improving both the country’s health services and the health status of the population will lead to a reduction in household expenditures and time spent seeking care. The poor will benefit particularly from the project’s drug safety activities as they are currently more likely to purchase and consume substandard pharmaceuticals.

25. Conclusion. The updated IEE concludes that if the measures prescribed in the EMP are fully implemented, it is unlikely that the project will have significant adverse environment, health and safety impacts. Environmental management and monitoring plans have been prepared, with budgets and responsibilities for implementation assigned. The EMP will be updated based on final design and will be submitted to ADB for review and approval prior to awarding the civil works contracts. Contractors during construction, and facility operators as well as MOH during operation will implement these measures. The effectiveness of these measures will be regularly evaluated in the framework of the environmental monitoring program, and corrective actions defined as required. The Government of Mongolia (GOM), through MOH, is committed to manage identified environmental risks and agreed on a comprehensive set of loan covenants.

26. Updated IEE addresses the project changes related to relocating car parking area, building an access road and two small additional buildings for medical gas storage and electricity generators. Environmental impacts and mitigation measures refer to construction impacts, which are common to the MON: Fourth Health Sector Development Project Additional Financing Project activities. Old hospital building will not be demolished, therefore there will be less impacts on air quality, traffic congestion and solid waste generation on site. Parking area and access road will be located on newly accessed land on the western side of the SDH site. Construction of these infrastructure will require same mitigation measures to reduce soil erosion, dust and noise control as well as management of the impacts from machinery operation, transport and haulage of materials and measures to ensure occupational and community health and safety as it was already covered in the initial IEE. Storage of medical gases must be stored in a separate building as required by the General Agency for State Inspection. There are two types of hazards, general fire and explosions and physical damage to compressed gas cylinders, associated with medical gas storage building. The storage building shall be designed in compliance with relevant national design standards and codes for medical pressurized gases.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

2. INTRODUCTION

2.1. Introduction and Purpose

28. ADB approved Grant 0236-MON: Fourth Health Sector Development Project on 29 November 2010 financed by the Asian Development Fund (ADF) grant of $14.0 million, $450,000 parallel cofinancing from the World Health Organization (WHO) and government contribution of $3.7 million. The project consists of three components to strengthen: (i) hospital services in Ulaanbaatar; (ii) human resources development; and (iii) drug safety.

29. In March 2012, the government requested additional financing to establish a new demonstration multifunctional general hospital in Songinohairkhan District of Ulaanbaatar instead of renovating the existing district hospital under component 1 of Grant 0236-MON. Loan 2932-MON: Fourth Health Sector Development Project – Additional Financing was approved on 5 November 2012 financed by an ADF loan of $25 million and a government contribution of $2 million. The loan agreement become effective on 14 June 2013 with current closing date on 31 December 2020. The loan consists of the same components as the grant.

30. The original Fourth Health Sector Development Project (FHSDP) planned to establish a demonstration multifunctional general hospital in Songinohairkhan District of Ulaanbaatar by renovating and expanding the infrastructure, equipping the hospital, and introducing innovative management systems. In May 2011, the Mongolian Parliament amended the health law requiring general hospitals to provide at least seven specialized medical services.1 The funding available under the original project is not sufficient to comply with the requirements under the amended health law. Considering the poor state of the infrastructure of the present Songinohairkhan hospital, the government is proposing to build a new general hospital, which will be used as a model to be replicated in the nine districts of Ulaanbaatar.2

31. The ongoing project (Grant 0236 and Loan 2932-MON) is performing well as it meets all the criteria including the review of safeguards compliance confirms that the project has no safeguards policy compliance issues and that each safeguard convent item is being complied. The component 1 is completed except the construction of the SDH, component 2 is 95% completed, and component 3 was fully completed in 2015. The overall progress in establishing the SDH is estimated at 55% as of October 2018.

32. On 16 November 2018, the government requested second additional financing to complete the SDH to address cost overruns caused by government requirements and regulatory changes introduced implementation of the ongoing project. The proposed additional financing does not involve any scaling-up of the current design of the SDH. Second additional financing was approved by ADB on 10 December 2018 for $16.00 million from ADB’s ordinary capital resources. The overall project is estimated to cost $61.31 million.

33. The additional financing is proposed to address cost overruns caused by works related to: (i) Government requirements for new regulations (earthquake, sound isolation, etc.); (ii) Limited restructuring of the building to answer requests made by nearby residents; (iii) Construction of buildings for electrical generators (40 m2) and medical gas (49 m2); (iv) Variations in quantities and volumes from the initial bill of quantities;

1 Amended Health Law. 2011. Article 16.12: General hospitals shall provide the population with health care and services in no less than 7 areas (internal, pediatrics, obstetrics, general surgery, dental care, neurology, infectious diseases) through the forms of ambulatory based and inpatient treatment and care. It may have a branch ambulatory based on location and health needs of the population. 2 The new hospital policy developed under the original project plans to establish 11 general hospitals to cover the population of Ulaanbaatar by 2020. 12

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

(v) Additional works, which were not part of the bidding document but are required by the state expertise; (vi) Additional costs linked to the implementation of the hospital access management plan. The existing SDH planned to deconstruct after completion of the new demonstration SDH to allow for sufficient space for car parking, access for patients, emergency services and hospital suppliers. The government objects to the deconstruction of the existing hospital because of shortages of overall health services supply in the district of Songinohairkhan.

34. To address the issue of lack of parking space and limited access, the government proposes to increase the space by freeing land on the western side on the SDH site. This will require resettlement of households in eight hashaa3. The funding for the resettlement is included in the 2019 budget of Ulaanbaatar City Mayor’s Office (UMCO) and could occur in May 2019, when the contractor constructs the parking space and a second access road around the existing hospital.

35. Based on the performance of the civil works contractors, the SDH construction can be completed as planned by 30 January 2020. The last batch of works drawings of the SDH were approved by the state expertise in April 2018 and submitted to the PIU and the civil works contractors.

36. The impact, outcome and outputs of the overall project will remain unchanged from the ongoing project.

37. The proposed additional financing will be implemented in 18 months from July 2019 to 31 December 2020 within the duration of the ongoing project. The implementation arrangements (i) executing agency; (ii) implementing agencies; and (iii) PIU will reaming unchanged from the ongoing project. Vamed Engineering GmbH, the construction contractor; and Ulaanbaatar City Investment Department and Junglim Architecture Co.,Ltd the construction supervisors under the ongoing project, will continue their respective roles under the overall project.

38. The procurement plan will be updated to include: (i) A contract variation for civil works package LW1 - $14.32 million (ii) A new civil works package for the construction of the parking space and the second access road of the hospital site - $1.68 million

39. This IEE is updated to reflect changes proposed under MON: Fourth Health Sector Development Project – Second Additional Financing. The Second Additional Financing of the Project will address the cost overruns caused by civil works under package LW1 and a new civil works package for the construction of the parking space and the second access road of the SDH site.

40. This updated IEE is based on the feasibility study, detailed engineering designs prepared during project preparation, site investigation by the existing safeguard team of the PIU and national consultant hired by ADB in close collaboration with, the MOH and UMCO. The updated IEE provides an assessment of potential environmental impacts and risks associated with the MON: Fourth Health Sector Development Project – Second Additional Financing components, and includes (i) a summary of the local, national, and international policies, standards, and guidelines; (ii) due diligence review of the project components; (iii) description of the project and anticipated environmental impacts and mitigation measures; (iv) information disclosure, consultation and participation; (v) grievance redress mechanism; and (vi) a detailed EMP, including implementation schedule and performance indicators.

3 Hashaa means compound; a hashaa might include more than one household. 13

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

41. The objectives of this updated IEE are to:

(i) Provide necessary baseline data about the project; (ii) Provide understanding on potential impacts of the project; (iii) Provide information on potential mitigation measures to minimize negative impacts including mitigation costs; (iv) Provide information on the public consultation process undertaken, and the project level Grievance Redress Mechanism (GRM) established; and (v) Formulate Environmental Management and Monitoring Plans (including definition of institutional responsibilities, capacity building and training plans, and budgeting).

2.2. Environmental Categorization, ADB and MON Approval of IEE

42. ADB environmental categorization. Environmental categorization for the ongoing FHSDP project is B and C for indigenous people and involuntary resettlement as per ADB’s Safeguard Policy Statement, 2009. The IEE and EMP was revised to address the environmental implications of the new Songinohairkhan demonstration hospital and approved by ADB in August 2012.

43. The Second additional financing categorization for environment and involuntary resettlement is B as the development of parking space and hospital access will require resettlements of households. The government will be responsible for the resettlement of the households in accordance with ADB’s policies and guidelines on involuntary resettlement (ADB Safeguard Policy Statement, 2009).

44. The principal impacts identified during screening related to the Songinohairkhan District Hospital will arise during construction. These are (i) increased traffic congestion near the project sites; (ii) increased noise and dust levels; (iii) the removal of some existing facilities including the existing hospital at the new hospital site; and (iv) occupational and community health and safety issues. These impacts are considered reversible and site specific and can easily be mitigated to acceptable levels through sound environmental management planning. The major infrastructure component of the project is Songinohairkhan District Hospital construction under Component 1 and is located in Ulaanbaatar. This infrastructure project is the primary focus of this updated IEE.

45. During operations, the main potential impacts relate to the proper management of medical and hazardous wastes from the SDH and an access to the new SDH. On medical wastes, the new SDH will be equipped with an integrated waste management system in detailed design in compliance with the 2011, MOH Orders 158 and 179 on Health Care Facility Waste Management. In addition, the hospital is located very close to the Ulaanbaatar Central Medical Waste treatment facility at the Naran Enger Landfill, which is proposed for improvement under the ADB Fifth Health Sector Development Project. A transportation management plan will be prepared to address access issues to the new hospital.

46. The development of parking space and building a second access road around the existing hospital on the western side on the SDH site will require resettlements of households. This will require resettlement of households in eight hashaa. The government will be responsible for the land acquisition and resettlement activities during project implementation in accordance with ADB’s Safeguard Policy Statement, 2009. The funding for the resettlement is included in the 2019 budget of Ulaanbaatar City Mayor’s Office (UCMO) and could occur in May 2019. An Involuntary Resettlement Plan will be prepared. The additional construction cost of the second hospital access, which will require more funds than initially planned, will be included in the project cost overrun.

47. MET environmental categorization. A formal request was submitted by the EA to the MET to conduct a General EIA, in accordance with the Mongolian Law on Environmental 14

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Impact Assessment (1998, amended in 2002) for the SDH. The General EIA was completed in July 2012 for the hospital and the general EIA concluded that a detailed EIA was required. The detailed EIA was approved by MET in August 2012. This IEE has addressed the specific requirements from MET.

48. IEE methodology. The following methodology has been implemented in the preparation of the IEE:

(i) Review of project-related documents and literature related to the project area. (ii) Preparation of detailed EIA requirements of the MET for the major activities, and incorporation of MET requirements into the updated IEE. (iii) Site visits to view conditions in project area and the location of the component projects, and screening of the project for potential impacts of concern. (iv) Consultation with local and national authorities to source information on project area characteristics and potential project impacts. (v) Identification of existing environmental and socio-economic characteristics to develop project baseline data. (vi) Analysis of typical environmental impacts of project components and identification of suitable mitigation measures to ameliorate potential impacts. (vii) Development of institutional arrangements for implementation of environmental management and monitoring. (viii) Formulation of IEE under ADB SPS requirements. This updated IEE has addressed the specific requirements from MET on this major project, as well as detailed EIA for the Songinokhairkhan District Hospital construction under Component 1.

2.3. Structure of this IEE Report

49. The updated IEE report is organized as follows:

(i) Executive Summary (Chapter 1) outlines important facts, major findings, and recommended actions of the IEE.

(ii) Introduction (Chapter 2) describes the purpose of this updated IEE, the environmental categorization by ADB and MET based on an environmental screening, and the structure of the updated IEE. (iii) Policy, Legal and Administrative Framework (Chapter 3) describes ADB’s and the Mongolian environmental impact assessment requirements and procedures, and applicable environmental regulations.

(iv) Description of the Project (Chapter 4) provides a justification of the project based on a sector analysis; a detailed description of the project, including project location and components.

(v) Description of the Environment (Chapter 5) defines the project’s area of influence and provides a description of the potentially affected environment. The description is based on reviews of available documentation, statistical data, meetings with experts in the field and field surveys and investigations. The ADB definition of the environment requires environmental assessments to address four aspects of the environment: (i) Physical Resources, including topography and soils, air and water quality, noise etc.; (ii) Ecological Resources – flora, fauna, and protected areas; (iii) Physical cultural resources; (iv) Socio- economic situation, including economic development, public health and education, and poverty; and (v) Land use.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

(vi) Analysis of Alternatives (Chapter 6) provides information on the project’s location and conceptual alternatives, as well as “No action” alternative.

(vii) Anticipated Impacts and Mitigation Measures (Chapter 7) provides an assessment of potential impacts of the proposed development in light of the existing conditions. Direct, indirect, induced and cumulative environmental impacts are assessed in this updated IEE. It assesses environmental impacts on soil, surface water, noise, flora, fauna, cultural heritage, health and safety, and social economy, during design, construction and operation. It also defines mitigation actions to prevent and/or otherwise mitigate unavoidable impacts expected to be incorporated as integral parts of the project.

(viii) Information Disclosure and Public Participation (Chapter 8) provides information on public consultation activities undertaken during project preparation and IEE update and introduces the plan for future public consultation.

(ix) Grievance Redress Mechanism (GRM) (Chapter 9) presents the GRM established (and refined at project inception stage) to handle grievances and complaints arising during project implementation. It defines GRM entry points, timeframe and institutional responsibilities of the GRM.

(x) Environmental Management Plan (Chapter 10) presents the updated EMP which defines the mitigation measures, performance indicators, environmental monitoring requirements, institutional responsibilities, training activities related to environmental management, reporting requirements, and a mechanism for feedback and adjustment.

(xi) Conclusions and Recommendations (Chapter 11) summarizes the major environmental impacts and mitigation measures, defines project risks and required project assurances, and concludes on the environmental soundness of the project.

(xii) References (Chapter 12) provide a list references used in the updated IEE.

(xiii) Annexes (Chapter 13) provide supplemental information. The full updated EMP is presented in Annex 1.

3. POLICY, LEGAL, AND ADMINISTRATIVE FRAMEWORK

3.1. Mongolia’s Environmental Policy

50. Mongolia has enacted a comprehensive policy and legal framework for environmental assessment and management. It has policies, legislation and strategies in place to manage the protected estate, to satisfy its international obligations, and to protect the quality of the environment for the health and well-being of its citizens. The hierarchy of policies and legislative provisions for environmental management in Mongolia comprises five layers ranging from the Constitution to international treaties, and to environment and resources protection laws.4

51. The main policy documents are the National Environmental Action Plan of 1996, the State Environmental Policy of 1997, the National Plan of Action to Combat Desertification, the Biodiversity Conservation Action Plan, and the National Plan of Action for Protected Areas, all developed under the MET auspices, as well as the Mongolian Action Program for the 21st Century. The National Environmental Action Plan was updated in 2000 and the National

4 UNDP. 2008. Institutional Structures for Environmental Management in Mongolia. Ulaanbaatar and Wellington. 16

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Action Plan for Climate Change was added in the same year. Several program documents (e.g. National Water Program, National Forestry Program, Program of Protection of Air, Environmental Education, Special Protected Areas, and Protection of Ozone Layer) were also completed at the turn of the decade. State policy on Environmental Impact Assessment was in place in 1998. In addition, other guidance documents with important environmental repercussions were developed under the auspices of other ministries and these include the Roads Master Plan, the Power Sector Master Plan, the Tourism Master Plan, and the Renewable Energy Master Plan. Other documents, such as the annual Human Development Reports have increasingly incorporated environmental aspects.

52. A fundamental principle of the Mongolian state environmental policy is that economic development must be in harmony with the extraction and utilization of natural resources and that air, water and soil pollution will be controlled. In April 1996, Mongolia’s National Council for Sustainable Development was established to manage and organize activities related to sustainable development in the country. The country’s strategy is designed for environmentally friendly, economically stable and socially wealthy development, which emphasizes people as the determining factor for long-term sustainable development.

53. The health of Mongolia's natural ecosystems and populations of wild species is of both national and global importance. The country forms an important part of the global ecosystem in the ecological transition zone in Central Asia, where the great Siberian taiga, the Central Asian steppe, the high Altai Mountains, and the Gobi Desert converge. In recognition of its global responsibilities, Mongolia has acceded to a number of international environmental conventions and the key ones are tabulated below in Table 1.

54. Each of these conventions places obligations on signatory governments ranging from the provision of a legislative basis for implementation, to adherence to the requirements and conditions of each convention, to monitoring implementation performance on a regular basis, to reporting on a regular basis and to the conference of parties.

Table 1. International Environmental Conventions Signed by Mongolia Convention Year of Accessio n World Heritage Convention 1990 Convention on Biological Diversity (CBD) 1993 UN Framework Convention on Climate Change (UNFCCC) 1994 UN Convention on Combating Desertification (UNCCD) 1996 Vienna Convention for the Protection of the Ozone Layer 1996 Montreal Protocol (regulating substances that deplete the ozone layer) 1996 Convention on International Trade in Endangered Species of Fauna and Flora (CITES) 1996 Convention on the Transboundary Movement of Hazardous Waste (Basel) 1997 Convention on the Protection of Wetlands of International Importance (Ramsar) 1998 Kyoto Protocol 1999 Rotterdam Convention on the Prior Informed Consent Procedure for Certain 2000 Hazardous Chemicals and Pesticides in International Trade Stockholm Convention on Persistent Organic Pollutants (POPs) 2004 Minamata Convention on Mercury 2015

55. The Government of Mongolia undertook a major environmental law reform in 1990 including the law of land, protected areas, water, forest, wildlife, and native flora resources. The legislation base is extensive as evidenced by the following table of key environmental legislation as shown in Table 2.

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Table 2: Key Mongolian Environmental Legislation Name of the Law Year Adopted and amendments The Constitution of Mongolia 1992 Law on Environmental Protection 1995, 2006, 2008, 2012, 2013, 2015, 2016, 2017 Law of Land 2002 Law on Land Cadastre and Mapping 1999 Law on Land Fees 1997, 2012 Law on Land Possession 2002. 2012, 2013, 2014, 2015, 2017, 2018 Law on Special Protected Areas 1994 Law on Buffer Zones 1997 Law on Water 2004 Law on Water and Mineral Water Resource Fee 1995 Law on Forests 1995 Law on Prevention of Steppe and Forest Fires 1996 Law on Reinvestment of Natural Resource Use Fees for Conservation 2000 Law on Natural Plants 1995 Law on Protection of Plants 1996 Law on Fauna 2000 Law on regulation of export and import of endangered species (flora, 2002 fauna) Law on Underground Resources 1994 Law on Mineral Resources 1997, 2006 Law on Petroleum 1991 Law on Air 1995 Law on Hydrometeorology 1997 Law on Protection from Toxic Chemicals 1995, 2008, 2011, 2015, 2017 Law on Environmental Impact Assessment 1998, 2002, 2015, 2017 Law on Tourism 1998 Law on Solid Waste 2017 Law on prohibiting export and transportation of Hazardous Waste 2012 Law on Air Pollution Fees 2010, 2012, 2015, 2018 Law on Air 2013, 2015, 2017, 2018

56. Relative to medical waste management, there have been significant regulatory changes at the Ministry of Health over the past few years. In 2009, a new strategy for medical waste management was implemented in Mongolia emphasizing the use of non- burning technologies. The action plan associated with this strategy included strategic improvement targets for medical waste management from 2009 to 2013.

57. The MON: Fourth Health Sector Development Project is being implemented in full compliance with these new MOH orders, the national strategy for medical waste management, and evolving management of hazardous chemicals from health care facilities (HCFs) in Mongolia. All equipment packages at the SDH will be designed in compliance with MOH Order 179 specifications.

58. Other Mongolian orders, regulations and guidelines related to hospital waste, hazardous waste and chemicals are listed in the Tables 3-6.

Table 3: Key Mongolian Orders, Regulations and Guidelines Related to Hospital Waste Name of Guideline, Order or Regulation Year Adopted

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Guideline on Production, Transportation, and Storage of Healthcare Related 1998 Gases by Joint Order No: A/172/167 of Minister for Health, Minister for Social Welfare, and Minister for Infrastructure in 1998.

Guideline on Waste Classification, Collection, Storage, Transportation and 2002 Disposal in Health Organizations by Joint Order No: 249/201 of the MET and MOH on October 17, 2002. “Requirements for pressurized gas cylinders and safety regulation” Minister of 2007 Energy, 04 December 2007, Order 93 Approval of Strategic Plan to Improve Healthcare Waste Management and Action 2009 Plan for Improving Healthcare Waste Management for 2009-2013, Order No: 293 by Minster for Health on September 9, 2009. “Procedures for Health Care Waste Collection, Sorting, Storage, Transportation, 2011 Disposal and Processing” MOH Ministerial Order 158, 2011. Requirements for Healthcare Waste Disposal Facility at Aimag Level; 2011 Requirements for Health Care Waste Disposal Facility at Soum, Village, Inter Soum Hospitals; Requirements for Bio-Waste Holes; Equipment List for The Health Care Disposal Facility at Aimag, Soum, Village and Inter-Soum Hospitals; Technical Specification for the Equipment Required for Health Care Waste Management, MOH Ministerial Order No. 179, 2011. Guidelines for Central Health Care Waste Disposal Facility Management, MOH 2011 Ministerial Order No. 380, 2011. Estimating Health Care Waste Assessment, MOH Ministerial Order No. 93, 2011. 2011

Safety Instruction on Mercury-Containing Items in Health Care Facilities; Safety 2011 instruction in the case of mercury spillage in health care facilities, as of 15 January 2011, to reduce the use of mercury-containing items such as mercurial thermometer, mercurial pressure gauge, to prohibit purchasing amalgam, to substitute with another products, Joint order by the Ministry of Health and National Emergency Management Authority, 2011.01.11 № 07/27.

Table 4: Key Mongolian Orders, Regulations and Guidelines Related to Hazardous Waste Name of Guideline, Order or Regulation Year Adopted Guideline on Reporting and Recording of Storage and Disposal of Hazardous 2003 Wastes by Order No: 127 of MET in July 1, 2003. Classification and Specification and Hazardous Level of Wastes by Order No: 2006 324/318/336 of MET, MOH, and Minister for Education, Culture and Science in 2006. “Regulation on Types of Landfill and Disposal Facilities and Centralized Waste 2006 Disposal Sites, Relevant Requirements and Specifications, and Procedures to be Conducted by Economic Entities and Individuals to Bury and Destroy Hazardous Wastes” by Order No: 404 of MET in 2006. Regulation on Issuing of Passport for Hazardous Wastes by Government 2006 Resolution No: 268 in 2006. Payment Calculation Methodology for Hazardous Wastes by MET in 2006. 2006 Regulation of National Reporting and Inventory of Hazardous Wastes by MET in 2009 2009.

Table 5: Key Mongolian Orders, Regulations and Guidelines Related to Chemicals Name of Guideline, Order or Regulation Year Adopted List of Products Containing Toxic and Hazardous Chemicals (Renewed In 2008) 2003 by Joint Order No: 126/171 by MET and MOH on July 1, 2003. Methodology of Calculating Waste Norms” by MET, in 2006. 2006 Regulation on Trans-Boundary Movement, Trade, Transportation, Export, and 2008 Import of Toxic and Hazardous Chemicals by Joint Order No; 92/90 of Minister for Nature, Environment, and Tourism and Minister for Foreign Affairs on December 29, 2008.

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Guideline on Methodology and Technology to Dispose, Storage, Transportation, 2009 Collection of Chemical Wastes; (2009) Regulation on Use, Transportation, and Import of Toxic and Hazardous 2009 Chemicals (renewed in 2009). Guideline on Transportation, Storage, Use, and Disposal of Toxic and Hazardous 2009 Chemicals and Guideline on Developing Risk Assessment of Toxic and Hazardous Chemicals” by Joint Order No: 28/40/29 of MOH, MET, and Chairman of National Emergency Management Agency on February 3, 2009. Guideline on Classification of Hazardous and Toxic Chemicals was Approved in 2009 2009. Joint order of the MET and of Health to endorse a regulation (on registration, 2012 collection, transportation, elimination, export, import, transit through the state border, production and trade of polychlorinated biphenyls) A.17/16. Joint order of the Ministers of Environment and Green Development and of Health 2012 and of the Director of the National Emergency Management Agency to endorse a regulation and methodology (regulation and methodology on risk assessment of toxic chemicals and hazardous substances) A.50/378/565. Joint order of the Ministers of Environment, Green Development and Tourism 2015 and of Health to approve classification of toxic chemicals and hazardous substances (classification of toxic chemicals and hazardous substances, methodology to use the classification of toxic chemicals and hazardous substances, list of substances related to toxic chemicals and hazardous substances) A/356/396. Joint order of the Deputy Prime Minister and the Ministers of Environment, Green 2017 Development and Tourism and of Health to endorse a regulation for storage, transportation, use and destruction of dangerous and toxic chemical substances 54/A/136/A/215.

Table 5: Key Mongolian Orders, Regulations and Guidelines Related to Water and Wastewater Name of Guideline, Order or Regulation Year Adopted Regulation of Fees on Water Pollution in 1992. 1992 Regulation of River and Water Source Protection Zone in 1992. 1992 Regulation of Lining Septic Tanks for Waste Water in 1995. 1995 Regulation for Registering Water Resource Pollution, Water 1996 Scarcity, Rehabilitation in 1996. Regulation on Water Resource Protection from Pollution in 1997. 1997 Regulation of Water Spring and Its Protection in 1998. 1998 Regulation of Establishing Wells and Water Points and Repair in 2005. 2005 Regulation of Conducting Water Source Inventory and Registration in 2006. 2006 Regulation of Creating Water Source Database and Cadastre in 2006. 2006 Order of the MET to endorse a regulation (on types of facilities and points for 2006 waste disposal and demolition, their requirements, operations of citizens and enterprises involved in waste disposal and demolition) 404 Joint Order of the MET and the MOH (rules on classification, collection, 2011 temporary storage, transportation and treatment of medical waste) A.320/305

3.2. Environmental Assessment Requirements

59. The MON: Fourth Health Sector Development Project – Second Additional Financing is subject to the environmental requirements of both Mongolia and those of ADB. These requirements are defined in the next two sections.

3.2.1. Environmental Assessment Requirements of ADB

60. Environmental safeguards requirements, including environmental impact assessment requirements, are defined in ADB’s Safeguard Policy Statement (SPS) of 2009. All projects funded by ADB must comply with SPS. The purpose of the SPS is to establish an environmental review process to ensure that projects undertaken as part of programs funded

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

under ADB loans are environmentally sound, are designed to operate in compliance with applicable regulatory requirements, and are not likely to cause significant environmental, health, or safety hazards. The SPS provides the basis for this IEE. With respect to the environment, the SPS is underpinned by the ADB Operations Manual, Bank Policy (OM F1, 2010). The policy promotes international good practice as reflected in internationally recognized standards such as the World Bank Group’s Environmental, Health and Safety Guidelines (General, Health Care Facilities and Waste Management).

61. Environmental assessment requirements of SPS specify that:

(i) At an early stage of project preparation, the borrower/client will identify potential direct, indirect, cumulative and induced environmental impacts on and risks to physical, biological, socioeconomic, and cultural resources and determine their significance and scope, in consultation with stakeholders, including affected people and concerned NGOs. If potentially adverse environmental impacts and risks are identified, the borrower/client will undertake an environmental assessment as early as possible in the project cycle. For projects with potentially significant adverse impacts that are diverse, irreversible, or unprecedented, the borrower/client will examine alternatives to the project’s location, design, technology, and components that would avoid, and, if avoidance is not possible, minimize adverse environmental impacts and risks; (ii) The assessment process will be based on current information, including an accurate project description, and appropriate environmental and social baseline data; (iii) Impacts and risks will be analyzed in the context of the project’s area of influence; (iv) Environmental impacts and risks will be analyzed for all relevant stages of the project cycle, including preconstruction, construction, operations, decommissioning, and post-closure activities such as rehabilitation or restoration; (v) The assessment will identify potential trans-boundary effects as well as global impacts; and (vi) Depending on the significance of project impacts and risks, the assessment may comprise a full-scale environmental impact assessment (EIA) for Category A projects, an initial environmental examination (IEE) or equivalent process for Category B projects, or a desk review.

62. Additionally, other key requirements of SPS include:

(vii) Environmental Management Plan. The borrower/client will prepare an environmental management plan (EMP) that addresses the potential impacts and risks identified by the environmental assessment. (viii) Consultation and Participation. The borrower/client will carry out meaningful consultation with affected people and other concerned stakeholders, including civil society, and facilitate their informed participation. (ix) Information disclosure. The borrower/client will submit to ADB the following documents for disclosure on ADB’s website: (i) a draft full EIA (including the draft EMP) at least 120 days prior to ADB Board consideration, and/or environmental assessment and review frameworks before project appraisal, where applicable; (ii) the final EIA/IEE; (iii) a new or updated EIA/IEE and corrective action plan prepared during project implementation, if any; and (iv) the environmental monitoring reports. (x) Grievance Redress Mechanism. The borrower/client will establish a mechanism to receive and facilitate resolution of affected people’s concerns, complaints, and grievances about the project’s environmental performance. (xi) Monitoring. The borrower/client will monitor and measure the progress of 21

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implementation of the EMP.

63. This updated IEE is intended to meet these requirements of SPS.

3.2.2. Environmental Assessment Requirements of Mongolia

64. The EIA requirements of Mongolia are regulated by the Law on Environmental Impact Assessment (1998, amended in 2002). The terms of the law apply to all new projects, as well as rehabilitation and expansion of existing industrial, service or construction activities and projects that use natural resources. The purpose of the law is environmental protection, the prevention of ecological imbalance, the regulation of natural resource use, the assessment of environmental impacts of projects and procedures for decision-making regarding the implementation of projects. The EIA process in Mongolia is summarized in Figure 1.

Figure 1: EIA Process in Mongolia Projects Requiring EIA Screening - New projects, renovation/expansion of industrial, service & construction activities, projects using natural resources

Project Implementer submits documents to MET or Aimag - Project description, Technical & Economic Feasibility, drawings, other related documents

MET or Aimag expert - Conducts General EIA (screening) within 12 days Makes 1 of 4 decisions

Decision 1 - Project can be implemented without Project Can Progress detailed EIA

Decision 2 - Project can be implemented with Project Can Progress specific conditions With conditions

Decision 3 - Project implementer - selects Detailed EIA Required Authorised Company for Detailed EIA

Decision 4 - Submit Detailed EIA - MET or Project rejected due to non-conformity or impacts Aimag expert decision within18 days

Source: Adapted from Vol. 1 (2001) Compendium of Laws: A Mongolian Citizens Reference Book

65. The type and size of the planned activity define responsibility for the MET or Aimag (provincial) government. There are two types of EIAs defined in the Law:

a. General EIA (screening) - to initiate a general EIA, the project implementer submits to MET (or Aimag government) a brief description of the project including feasibility study, technical details, drawings, and other information. The general EIA may lead to one of four conclusions: (i) no detailed EIA is necessary; (ii) the project may be completed pursuant to specific conditions; (iii) a detailed EIA is necessary; or (iv) project cancellation. The general EIA is free and usually takes up to 12 days.

b. Detailed EIA – the scope is defined by the general EIA. The detailed EIA report must be produced by a Mongolian company which is authorized by the MET by

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means of a special procedure. The developer of the Detailed EIA should submit it to the MET (or Aimag government). An expert of the organization who was involved in conducting general EIA should make a review of the detailed EIA within 18 days and present it to MET (or Aimag government). Based on the conclusion of the expert, the MET (or Aimag government) takes a decision about approval or disapproval of the project.

c. The detailed EIA must contain the following chapters: (i) environmental baseline data; (ii) project alternatives; (iii) recommendations for minimizing, mitigation and elimination of impacts; (iv) analysis of extent and distribution of adverse impacts and their consequences; (v) risk assessment; (vi) EMP; (vii) environmental monitoring program; and (viii) opinions of residents on whether the project should be implemented.

66. In both major MON: Fourth Health Sector Development Project Additional Financing Components, MET required a detailed EIA to be prepared. The detailed EIA for the Central Laboratory was approved by MET in 2010. MET required a detailed EIA for the construction of SHD in 2012. The detailed EIA for the construction of Songinohairkhan hospital was approved by MET in August 2012. This IEE addressed the specific requirements from MET on both of these major components.

3.3. Other International Environmental Requirements

67. The World Bank Group’s Environmental, Health, and Safety (EHS) guidelines are technical reference documents with general and industry-specific examples of Good International Industry Practice (GIIP). The EHS guidelines are provided in a general set in four major categories (environmental, occupational health and safety, community health and safety, construction and decommissioning.) These general guidelines are supplemented by relevant Industry Sector specific EHS guidelines. For the MON: Fourth Health Sector Development Project - Second Additional Financing, the General EHS Guidelines apply as well as those for Health Care Facilities and Waste Disposal Facilities. These relevant EHS for HCFs will be applied to the MON: Fourth Health Sector Development Project – Second Additional Financing structural components and small equipment installations during the detailed design. Annex 2 outlines how these General EHS for HCFs are being applied to the MON: Fourth Health Sector Development Project – Second Additional Financing structural components.

3.4. Mongolia HCF Environmental Infrastructure

68. The PPTA consultant for the original FHSDP reviewed environmental issues related the health care facilities (HCF) in Mongolia. The specific text of the project preparation technical assistance terms of reference was: • Undertake an analysis of and propose measures to address the constraints in providing safe water and sanitation, proper waste disposal, and efficient heating systems for health facilities in urban and rural settings.

69. This review in 2010 uncovered some problematic issues historically associated with health care environmental infrastructure in Mongolia but also many current encouraging steps being taken. Since the review was completed, MOH has implemented an integrated medical waste management program and developed several new orders on medical waste management (158, 179, 380), and the program is being implemented on a consistent basis in the country following these orders. The following is a summary of the major conclusions from the 2010 PPTA:

• Medical waste management activities had been rather disjointed in the past, but now are moving toward more coordinated path and trajectory through the recent

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formation of the Joint Action Committee on Medical Waste Management. Moving all of the relevant stakeholders and donors in the health sector on the same and coordinated strategy using this Joint Committee Action Plan (2009) is a good first step in improving environmental management at HCFs in Mongolia.

• For overall environmental infrastructure issues beyond waste management, a systematic technological evaluation of appropriate, cost-effective and sustainable solutions to water and sanitation, waste and heating system infrastructure at the sector level is required, and then applied to project evaluations.

• There is a pressing need to prepare proper technical specifications for various environmental infrastructure solutions at HCFs, which many times are based only on a single vendor proposal.

• HCFs require a significant level of environmental infrastructure outside or downstream of the HCFs. In cities, this could mean an adequate supply of quality potable water for HCFs, downstream operational wastewater treatment plants (WWTPs) where centralized sewerage systems are available, and proper conventional and medical waste disposal sites. Adequate centralized heating systems are also required for many areas. These regional environmental infrastructure systems are somewhat lacking in many cases, especially for HCFs outside of Ulaanbaatar.

• For Ulaanbaatar, the construction of a centralized medical waste management facility (run by MOH-Licensed Medical Waste Company) at the recently upgraded Naran Enger Landfill is a very good first step in medical waste management in the capital city. However, this facility has not had a detailed technical evaluation or environmental assessment (MET indicates that an EIA is being prepared) and may not currently meet all appropriate international environmental norms. The facility will be upgraded in the framework of the proposed MON: Fifth Health Sector Development Project, which will be implemented in parallel to this project.

70. The MON: Fourth Health Sector Development Project - Second Additional Financing has been developed within these constraints. The SDH is served by Ulaanbaatar central water supply, wastewater collection and treatment facilities, centralized drainage systems, centralized heating systems and available electrical supply. This hospital is also located very close to the recently upgraded Naran Enger landfill and the new MOH-Licensed Medical Waste treatment facility. Since the MON: Fourth Health Sector Development Project- Second Additional Financing is only involved with infrastructure in Ulaanbaatar, many of the problems outlined in the HCF environmental review are less serious than in other parts of Mongolia.

71. The MET is currently working on implementing an existing feasibility plan for a large hazardous waste treatment facility to serve Ulaanbaatar and surrounding areas. Although the funding for the facility is not yet guaranteed, the MET is confident that it will be designed and constructed before the end of this 10-year period.

4. DESCRIPTION OF THE PROJECT

4.1. Overview

72. The MON: Fourth Health Sector Development Project – Second Additional Financing is being financed through a combination grant and loan between the ADB and the GOM. The project will strengthen the hospital sector in Ulaanbaatar and improve drug safety nationwide. The Project builds on previous health sector development initiatives to continue reforming the Mongolian health sector, including health care financing, in line with the National Development Strategy and the government’s Health Sector Master Plan (2006–2015). The impact, outcome

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and outputs of the overall project is unchanged from the ongoing project.

73. Impact and outcome. The impact of the project will be improved quality of health services in Mongolia. The outcome will be improved patients and health workers safety in hospitals in Mongolia through implementation of a model multi-functional hospital, strengthened medical training and improved drug regime for the country. The project geographic focus is in Ulaanbaatar, but the improvements will have benefits for the entire country, by providing a model multi-functional hospital and improved drug safety.

74. Under this overall structure, the MON: Fourth Health Sector Development Project – Second Additional Financing will have three components with the following outputs:

a. Component 1: Strengthened Hospital Services in Ulaanbaatar. As part of reforming the hospital sector, the Project will assist the government in establishing the Songinohairkhan district hospital (SDH). The SDH of Ulaanbaatar will be turned into a multifunctional general hospital that will provide quality services to the district population and serve as a demonstration hospital for other districts in the city. The other outputs for this component have already been completed under the overall project. b. Component 2: Strengthened Human Resource Development. The Project supported developing a hospital management module and including it among the programs offered by a local training institution. The outputs under this component have already been completed under the overall project. c. Component 3: Strengthened Drug Safety Regime. The Project increased access to safer drugs nationwide, strengthened drug regulatory functions, upgraded the drug control laboratory to international standards, upgraded the standards of good manufacturing processes for drugs, strengthened drug post- marketing surveillance and adverse drug reaction, and improved drug safety governance functions of the Ministry of Health (MOH). The outputs under this component have already been completed under the overall project.

75. The ongoing project (Grant 0236 and Loan 2932-MON) is performing well as it meets all the criteria including (i) the delivery of expected outputs is rated successful (component 1 is completed except the construction of the SDH, component 2 is 98% completed, and component 3 was fully completed in 2015); (ii) the project is rated on track under the project performance system; (iii) the review of safeguards compliance confirms that the project has no fiduciary and safeguards policy compliance issues and that each safeguard covenant item is being complied with; and (iv) the management of risks is rated successful as all the risks included in the Risk Assessment and Risk Management Plan have been managed successfully; As of Dec 2018, the overall progress in establishing the SDH is estimated at 63% and it is planned to be completed in January 2020.

76. In November 2018, the government requested a second additional financing to complete the SDH to address cost overruns caused by (i) government new regulations introduced during implementation of the ongoing project (e.g., improved seismic resistance and sound insulation); (ii) limited restructuring of the building to answer requests made by nearby residents; (iii) construction of an electrical substation and a medical gas building to conform to existing regulations; (iv) variations in quantities and volumes from the initial bill of quantities; and (v) additional costs linked to the implementation of the hospital access management plan. 5 The proposed additional financing does not involve any scaling-up or modification to the current design of the SDH.

5 The government objects to the deconstruction of the existing hospital planned under the ongoing project because of shortages of overall health services supply in the district of Songinohairkhan. The presence of the existing hospital requires rerouting of the hospital access road and resettlement of a limited number of households to ensure access for patients, emergency services and hospital suppliers; and sufficient parking space for visitors. 25

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

77. The additional financing is considered to meet the four eligibility criteria for additional financing.6 First, ADB reviewed the current project in Dec 2018 and confirmed the satisfactory performance and that no significant changes in approaches and methodologies were envisioned. Accordingly, the current project remains technically feasible, economically viable, and financially sound. Second, the government accords high priority to the ongoing project given its critical role in the position of quality health care services in the poorest district in UB. Moreover, the SDH represents a concrete step in implementing the 2011 amended Health Law to provide a broader range of services in district hospital. The SDH will also serve as a model to be replicated in other districts of Ulaanbaatar. Third, the project outcome, outputs and project scope of the overall project remain unchanged from the ongoing project and consistent with the project’s development objectives. Fourth, the overall project is consistent with the country partnership strategy for Mongolia, 2017–2020, which emphasizes social development through efficient delivery of health services.

78. The overall project7 will directly benefit over 320,000 (mostly poor) residents of the Songinohairkhan district of Ulaanbaatar by improving district hospital services. The overall project is and will continue to benefit the entire population of Mongolia by improving access to safer drugs. In the longer-run, the overall project will improve allocative efficiency in the health sector by optimizing the use of hospital services and improve return on future investment in the hospital sector.

79. The overall project will provide the government with a strategic framework to improve hospital services rationally and develop plans that make the best use of the resources available. A demonstration multifunction secondary hospital based in Songinohairkhan district will be completed to support the reform of the hospital sector and provide a model which could stimulate interest in a new mode of service delivery and consequential further investments. The overall project has also assisted the government in strengthening drug regulatory functions and improve greatly the coordination among several stakeholders involved in dug regulation.

80. Project Costs. The original FHSDP project cost was estimated at $18.15 million, financed by an Asian Development Fund (ADF) grant of $14 million and $450,000 parallel cofinancing by the WHO, with the government to finance the balance of $3.70 million. The Fourth Health Sector Development Project Additional Financing budget (including both the original budget and the additional financing) is estimated to cost $42.83 million, of which additional financing from ADF loan is $22.68 million and from government contribution is $2.0 million, resulting in an overall increase in financing of $24 million. The government has requested second additional financing as a regular loan of $16.00 million from ADB’s ordinary capital resources to help finance the overall project or 35.44% of the originally approved project financing amount. The overall project is estimated to cost $58.99 million. ADB will finance 99.01% of the additional financing cost ($16.00 million), and the government will finance $0.16 million for project implementation of the second additional financing.

4.2. Songinohairkhan District Hospital

81. The existing hospital site plan is shown on Figure 2. The SDH is connected to the Ulaanbaatar centralized systems for water supply, wastewater collection and heating systems. In addition, the hospital is very close to the existing Ulaanbaatar Naran Enger landfill and MOH-Licensed centralized medical waste treatment facility. As such, the project designers have only minimal concerns for environmental infrastructure but will provide a suitable waste transfer station for medical and conventional wastes. The medical waste management

6 ADB. 2018. Bank Policies. Operations Manual. OM H5. Manila (para. 4). 7 The overall project refers to the original project and the additional financing. The significant expansion of the hospital output under the additional financing will bring about modification of selected procurement and consultant packages, as well as resulting reallocation of grant proceeds under the original project, as further detailed in the PAM. The modified original project is qualified as the “adjusted original project” in the PAM. 26

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

systems will be designed and constructed in full compliance with MOH Orders 158 and 179 of 2011.

Figure 2: Site Plan of Existing Songinohairkhan District Hospital

Photos 1, 2: Front and Back of Existing Songinohairkhan District Hospital Site

82. The Songinohairkhan hospital was established in 1982 and received district status in 2001. It currently has 75 beds in the children’s unit, 35 beds in the internal medicine unit and 5 beds in the emergency and rehabilitation unit, for a total of 115 beds. The 2011 statistical data indicates 48,546 bed/days, average bed/day of 6.1, and a clinic mortality rate of 0.07%. 27

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

There is currently a total of 103 workers at the hospital, including 23 doctors, 36 nurses and 44 administration workers.

83. The existing hospital service is divided into main and secondary service. Main services for adults include general and neurological treatment. Main services for children include general treatment and hospitalization. Secondary service consists of:

a. Para clinical unit (Laboratory/biochemistry, Clinic, immunology, x-ray, physical treatment, dietary treatment, drug store, pathology/anatomy, laundry and statistic) b. Miscellaneous (Canteen, warehouse, archive, garage, clinical waste storage point, morgue) c. Administration

84. Although they were originally constructed in 1982 as a single facility, the Ambulatory 1 of the Health Union of Songinohairkhan district is now operated separately for emergency services, while the hospital operates mainly for in-patients (see site plan). This operational scheme will be evaluated as part of the proposed new hospital in this project and may be adjusted. Ambulatory 1 is located contiguous to the hospital and has a two-story building also connected to centralized water supply, electricity, heat and potable water. Ambulatory 1 serves a population of about 52,000. There are 15 medical disciplines (otolaryngology, gynecology, gastrology, ophthalmology, dental section, laboratory, traditional treatment, imaging diagnosis, surgery, immunization, juvenile and physical treatment, allergy and cardiology). Ambulatory 1 has 42 professional staff, including 15 physicians and 16 nurses.

85. The new ambulance control center manages the ambulances from the site. Although the ambulatory and ambulance control center are shown as separate land parcels, all are owned by the City of Ulaanbaatar. As such, some potential lot line adjustments to service the proposed hospital are possible.

86. The canteen, garages, central heating control and hot water boiler station and medical waste storage shed will be demolished prior to hospital construction. The existing hospital will convert an existing room for medical waste storage room during construction of the new hospital. The new hospital design will include a medical waste storage system in compliance with MOH Orders 158 and 179 of 2011. The central heating control room will be relocated prior to construction and the new hospital will be equipped with its own hot water system. A temporary canteen will be organized by the existing hospital.

87. There is an existing heating tunnel from the control station to the existing hospital as well as many other utility lines. The heating tunnel and other utilities will need to be relocated to accommodate the new hospital, and new connections to the existing hospital made for the construction period. For the heating system, this must be done between 15 May and 25 September, when heating system is off in the city.

88. The proposed hospital will be approximately 18,000 m2 in six stories of about 3,000 m2 each. Final design may modify this configuration to be less stories with larger footprint, but this is considered a “worse case” design for environmental purposes. The new hospital will comprise a children’s department, internal medicine, trauma unit, neural, obstetric and gynecological units with a total of 280 beds to serve patients. The proposed distribution of rooms is shown in Table 7.

Table 6: Proposed Hospital Design Parameters Name of Section and Departments Rooms Beds Emergency 3 Observation Beds Adults 2 2 Infants 1 2 Shock Room 1 1 Treatment 1 2 28

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Plaster Room 1 Outpatient Department 25 General Medicine 5 Pediatric 5 Surgery 4 Ob Gyn 4 Neurology 1 Ophthalmology 1 ENT 1 Traditional Medicine 1 Injection / Treatment 2 Dental 6 Functional Diagnostics Cardiology 1 Physiotherapy and Rehabilitation 10 Electrotherapy 1 Phototherapy 1 Microwave Therapy 1 Ultrahigh Free Therapy 1 Electro-sleep Therapy 1 Thermotherapy 1 Exercise Therapy Room (Gym) 1 Mechano-therapy 1 Massage Rooms 2 Hospitalization 5 Medical Ward 2 22 Surgical Ward 2 22 Trauma Unit (Part of Surgical Ward) 1 22 Obstetrics and Gynecology Ward 2 22 Pediatric Ward 3 22 Infectious Disease (Part of Medical Ward) 1 22 Neurology and traditional Medicine 1 22 (included in Medical Ward) ICU Adults 1 16 % out of total beds 5.71% Surgery General Surgery 4 Recovery 1 8 Obstetric Bloc Labor Rooms 1 6 Delivery Rooms 3 Post-Partum 1 6 Imaging Diagnostics General Ultrasound 2 General X Ray 3 Mobile X Ray 1 Laboratory 4 Biochemistry 1 Hematology 1 Microbiology 1 Blood Bank 1 Teaching and Training Area Name of Section and Departments Rooms Beds Classroom 1 30 Administration Direction 1 Admission 1 Medical Records 1 Procurement 1 Clinical Support Services Pharmacy 1 CSSD 1 Morgue and Anatomy Pathology 1 Non-Clinical Support Services 2

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Kitchen 1 Laundry 1 Engineering and Maintenance 1 Waste Management 1 Central Stores 1 Transport 1 Security 1 Cleaning 1 Public areas 1 Cafeteria 1 Hospital Beds 280 Non-Sensible Beds 27 Total 307

89. The Initial Site Plan of Songinohairkhan Hospital shown in Figure 3.

Figure 3: Initial Site Plan of Proposed Hospital

90. In order to make the hospital building construction coherent with urban development and requirements for internal road and streets, and requirements of hospital activities ingress and egress standards, the following activities are planned:

a. Initial demolition of small structures and relocation of internal site utilities; b. Establishment of interior road network loop, using existing north and new east access points to serve the new hospital and other users adjacent to hospital; c. Existing street on east side of site will be main entrance to the hospital; d. According to MOH hospital design standards, the hospital building should not be more than 40% of the total hospital area, and will require establishment of 5000 m2 of greenery area; and e. A large ground level parking area in two sections of the lot is necessary.

91. The proposed hospital will require at least 3 entrances, which are:

a. Main entrance and exit; b. Emergency entrance and exit; and c. Solid waste and stand by equipment reception entrance and exit.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

92. The main entrance and one additional entrance are located in the existing eastern street, while the existing driveway to the northern street will be improved. Construction of the new hospital will involve careful phasing to maintain the existing hospital service until the new hospital is complete and operational.

93. Schedule 5 para. 10 of the loan agreement planned the deconstruction of the existing SDH after completion of the construction of the SDH to allow for sufficient space for car parking and greenery (Figure 3). Schedule 5 para. 11 planned the site access during construction and operations by ensuring access for patients, emergency services and hospital suppliers. The government objected to the deconstruction of the existing hospital because of shortages of overall health services supply in the district of Songinohairkhan especially with high number of pediatric cases during the winter season. If the existing hospital is not deconstructed, there will be a restricted parking space for visitors of the hospital and the site access during operations will be seriously hampered as the SDH will be left with a single access. This single access would also accommodate residents leaving around the hospital and the access of the fire brigade in case of fire in the SDH. To address the issues, the government proposes to increase the space for car parking and to build a second access road around the existing hospital by freeing land on the western side on the SDH site. The parking area will be relocated about 25m to west of the originally planned site and alignment of hospital access road will be changed to build second access road around the existing hospital to ensure proper site access for patients, emergency services and hospital suppliers. The revised site planning for access road, additional parking area, medical gas storage and generator buildings are shown in Figure 4. and google map for the Songinoharkhan hospital is in Figure 5.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Figure 4: Revised Site Planning for Access Road, Additional Parking Area, Medical Gas Storage and Generator Buildings

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Figure 5: Google Map - Songinohairkhan Hospital Site

94. Besides the overall phasing of work, utility systems will need to be relocated to allow continuous service to the existing hospital, Ambulatory and ambulance control center. As such, proposed utility relocation plans have been developed as shown in Figure 6 through Figure 9.

Figure 6: Proposed Water Supply Relocation Plan

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Figure 7: Proposed Sewerage Relocation Plan

Figure 8: Proposed Heating System Relocation Plan

95. The SDH is connected with the Ulaanbaatar central electrical grid and heating system. Two generators as an additional source of electricity and medical gases were planned to be placed in the ground floor of the new hospital. However, the General Agency for State Inspection required to relocate then in two separate buildings outside the hospital. Medical gas storage and generators buildings will require 40m2 and 49m2 built area respectively. These small buildings can easily be accommodated in the hospital premises and currently planned on north-west corner of the hospital site (Figure 4). Oxygen, anesthetic (N2O) and CO2 gas cylinders will be stored in the building.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Figure 9: Proposed Electrical System Relocation Plan

96. In addition, telecommunications lines must also be relocated around construction zone.

97. In accordance with project planning, the total of 449 employees will be located in the new Songinohairkhan hospital, including 103 physicians, 155 nurses, 28 other medical specialists, 34 technicians, 62 administrative staff and 67 service and assistant workers (engineers, technician, cleaning, kitchen and washing).

98. The detailed design of the hospital will take into account the severe climate conditions of Ulaanbaatar and appropriate insulation systems be installed. Detailed design will also incorporate the following climatic factors relative to construction of the new Songinokhairkhan hospital: a. Air temperature: + 39 to -39 degrees C. b. Snow weight: 50 kilogram / square meter c. Wind impact; 35 kilogram / square meter d. Earthquake scale: 7 scale

99. Training and Capacity Building. The project will also provide significant training in the proper operations of the new hospital including the integrated waste management system. The project includes 34 person-months of international experts in hospital operations and drug related training work and 57 person-months of national consultants. The project training ensures that operations of the new Songinohairkhan hospital is done in a technically, environmentally, healthy and safe manner.

5. DESCRIPTION OF THE ENVIRONMENT (BASELINE DATA)

100. Most of the MON: Fourth Health Sector Development Project – Second Additional Financing activities will have minimal impacts to the environment and will not be influenced by current environment conditions. The major infrastructure project with potential impacts to the environment is the construction of the SDH under Component 1 located in Ulaanbaatar. Thus, the main emphasis of this chapter is the description of physical, biological, and socioeconomic conditions in Ulaanbaatar, and more specifically the environment at the site where the replacement hospital will be constructed.

5.1. Physical Environment

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

101. Geology. Geologically the Ulaanbaatar region belongs to the Khentii geosynclinals depression. Ulaanbaatar City is mainly underlain by Cambrian, Devonian, and Carboniferous sandstone and mudstone. Ulaanbaatar City is located on an alluvial plain. MET confirmed that in the City, soil is low in permeability and gullying and erosion is visible on steep slopes in the ger areas to the North of the City.

102. Climate. Mongolia has a severe continental climate. Ulaanbaatar is the coldest national capital in the world, with temperatures ranging from approximately -30 0C to +250C. The country is also prone to severe winters, known as zud which means any condition that stops livestock getting to pasture. The winters of 1999, 2000, 2001 and 2010 were zud years, which resulted in the deaths of more than 25% of the livestock population. Ulaanbaatar is located at 1,350m altitude in the valley of four mountain ranges which rise to 1,650 to 1,949m altitude. Due to its location the city experiences many temperature inversions. At least 80% of these inversions occur from October to April when air temperatures are from 7.5 to 11.7 0C and land temperatures are from minus 21 to minus 39 0C. The average depth of the inversions is 650 to 920 m.

103. Precipitation. The country averages 257 cloudless days a year, and it is usually at the centre of a region of high atmospheric pressure. Precipitation is highest in the north, including Ulaanbaatar (average of 200 to 350 mm per year) and lowest in the south, which receives 100 to 200 mm annually. In Ulaanbaatar, 95-97 percent of precipitation falls during the warm season, including 75-80 percent in the summer. In winter, the precipitation ranges from 1 to 3 mm, whereas in July it ranges from 100 to 120 mm. In average it rains 40-70 days a year, snow falls on 25-30 days, and land is covered with snow for 140-170 days.

104. Wind. The dry environment exacerbates the frequent dust storms occurring in Mongolia each year. Wind erosion of soil is a dynamic process of soil degradation in which the share stress applied on the ground surface by wind exceeds the ability of the soil particles to resist separation and transportation. The wind erosion depends on the climatic factors, soil properties, landscape characteristics and availability of vegetation. In Ulaanbaatar, wind blows mostly from the north and northwest and average wind velocities are usually lower than in other parts of Mongolia. Monthly wind velocities average 1.6 – 4.4 m/s, with an average of 7 to 9 days per year where wind velocities exceed 10 m/s.

105. Permafrost. The area of permafrost near Ulaanbaatar has been receding in recent years and does not affect either the new Songinohairkhan hospital or the Central Laboratory. Figure 10 shows the regional distribution of permafrost near Ulaanbaatar in dark blue areas, now relatively far from urban area. At the new hospital site, the seasonal melting depth is between 2.8-3.2 meters so there should be no impact on construction of the new hospital.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Figure 10: Distribution of Permafrost Near Ulaanbaatar

106. Surface water. Ulaanbaatar is located in the Tuul River basin. The Tuul River is 704 km long and drains an area 49,840 square km. Currently the Tuul River is suffering from pollution, some caused by Ulaanbaatar’s central sewage treatment facility, as well as heavy mineral and sedimentation pollution caused by gold mining in the Zaamar area. The Selbe River, a tributary of the Tuul River with a catchment area of 303 square km, flows along the Eastern and Southern sides of Ulaanbaatar, eventually meeting the Tuul River approximately 20 km downstream of the City. The principal recharge mechanism for the Selbe River is the rain water in summer and autumn therefore, water levels fluctuate considerably. The river is considered to be of low biological relevance and is not used as a drinking water source or for agriculture.

107. Poor urban planning has meant many city development activities have been implemented near the Tuul River and in its watershed including the Selbe River. This has led to the degradation of water quality, exacerbated by pollution (sewage and garbage) from unplanned settlements, particularly in the ger areas. While long term average water quality in the Tuul and the Selbe remain satisfactory (Table 8), quality rapidly deteriorates during low flow periods.

Table 7: Average Water Quality in the Selbe River in Ulaanbaatar (1998-2008) + -3 -2 pH SS DO BOD5 NH4 PO4 SO4 [-] [mg/l] [mg/l] [mg/l] [mg/l] [mg/l] [mg/l] Selbe River in 8.1 30.9 9.4 2.9 0. 0.02 24.6 Ulaanbaatar 3 MON standard for 6.5-8.5 - 6.4 3.0 0. 0.1 100 ambient water 5 quality Source: Altansukh O. 2008. Surface Water Quality Assessment and Modeling. A case study in the Tuul River, Ulaanbaatar City, Mongolia. Master Thesis. International Institute for Geo-information Science and Earth Observation. Enschede, The Netherlands.

108. The new Songinohairkhan district hospital is located far from these rivers or any other water bodies in the city. 37

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

109. Groundwater. Groundwater exists in unconfined aquifers (alluvial sediments of late quaternary to recent period) at depths between 4 - 30 m. The static water level in the Tuul River valley is from 2 - 6m in winter and 0.5 - 5 m in summer, if there are no wells in operation. However, extraction of groundwater can cause the static water level to drop from 10 - 13m in winter and from 15 - 19m in summer. There is no current groundwater information near the new Songinohairkhan district hospital, but it is assumed at the higher depths since they are not close to water bodies.

110. Air quality. Air pollution in Mongolia is severe. Air pollution in the capital Ulaanbaatar surpasses standard levels with the adverse effect on the population’s health and well-being as well as environmental balance. A World Bank study states that Particulate Matter (PM) is the largest and relatively most severe air pollution problem in the City. In terms of PM, Ulaanbaatar is among the most polluted cities in the world. The main sources of air pollution including PM2.5 (fine particulates) are from heating and cooking, traffic and industrial sources such as coal fired power stations. Many of the diesel and petrol-run vehicles are outdated and do not meet environmental and safety standards.

111. The National Agency for Meteorology and Environmental Monitoring operates a network of 12 air quality monitoring stations situated in Ulaanbaatar. Data are collected and coordinated by the National Agency. Figure 11 gives the locations of 9 of the 12 air quality stations for which data were available and shows noise monitoring stations in the City. The closest air quality monitoring station to the replacement Songinohairkhan district hospital is UB4, and the closest noise monitoring site is N13 Sansar. The closest air quality monitoring station to the new Central Laboratory is UB-2 and the closest noise monitoring station is N8 Duuri.

Figure 11: Air Quality and Noise Monitoring Stations in Ulaanbaatar

112. Annual average concentrations of PM10 are measured at the National University of Mongolia campus, close to the city centre, more than 5 kilometers from the Songinohairkhan district hospital. Average yearly PM10 concentrations were as high as 104.9, 97.7 and 104.8 µg/m3 for 2015, 2016 and 2017 respectively. 38

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

113. Further measurements at monitoring stations conducted in June 2008 (under World Bank’s Air Monitoring and Health Impact Baseline Study) give even higher PM10 concentration levels. Recorded levels exceeded the Mongolian air quality standard (100 µg/m3), World 8 3 Health Organization (WHO) guideline value (50 μg/m 24 hour mean PM10) and the European limit value (40 µg/m3). In addition, extremely high concentrations of PM were found at the mobile PM stations under World Bank’s Air Monitoring and Health Impact Baseline Study in the ger areas. Mostly during winter months, some days recorded levels of up to 4000 µg/m3, although the report states that this value should be revised down by 40%9 due to interference in the results by the relative humidity at the time of sampling.

114. More recent data for November 2018 are given in Table 9. The data show similarities with that presented by the World Bank for PM10. Available limits for PM10 continue to be exceeded throughout the city.

115. Table 9 also gives Sulphur Dioxide (SO2), Nitrogen Dioxide (NO2), Carbon Monoxide (CO) and PM2.5 values. It can be seen that the Mongolian Air Quality Standards were frequently breached in November 2018. Also, WHO’s comparable guideline value (24 hour 3 mean) for SO2 of 20 μg/m is also exceeded regularly.

Table 8: Air Quality Measurements & Mongolian Standards 2018 3 3 3 3 November 2018 SO2 µg/m NO2 µg/m PM10 µg/m PM2,5 µg/m

Average 59 210 135 164 UB2 Max 124 420 307 476 Average 59 168 180 126 UB4 Max 104 268 294 234 Average 41 122 189 No data UB5 Max 78 164 399 No data Average 39 110 224 No data UB7 Max 88 196 393 No data Average No data 57 147 No data UB8 Max No data 110 362 No data Mongolian Standard (24 hr mean) 20 40 100 50

Source: Air pollution database, MET - www.eic.mn/airpollution

116. Noise. Noise measurements were made by the Central Laboratory of MET at 14 locations using mobile equipment. Ambient noise levels throughout the city centre are consistent with little fluctuations (Table 10). Average noise levels comply with Mongolian standards, but periodically exceed the standards especially along transport corridors, as traffic is a major source of noise in the urban area along with construction noise. These data are further supported by monitoring for a domestic EIA report which observed noise levels in the City at 62 dB at the curbside in peak hour traffic, dropping slightly to 61 dB at the wall of the closest building at ground level. This figure reduces to 59 dB at 4 meters above ground.

8 WHO. 2005. Air Quality Guidelines. Summary including guideline values available at http://www.who.int/mediacentre/factsheets/fs313/en/index.html. 9 World Bank (December 2009) Air Pollution in Ulaanbaatar: Initial Assessment of Current Situation and Effects of Abatement Measures Discussion Paper. 39

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Table 9: Noise Measurements dB Monitoring Point Location 2009 Average 2010 Average N1 Tolgoit 53.7 49 N2 Devshil 56.7 No Data N3 Yarmag 56.5 49.25 N4 Bayankhoshuu 54.5 50.25 N5 Zuragt 57 No data N6 3rd Hospital 56.4 No data N7 Tsengeldeh 55.8 No data N8 Duuri 59 No data N9 4th school 61.3 No data N10 17th school 57.2 No data N11 Ulaankhuaran 53.2 59 N12 Amgalan 52.5 51.75 N13 Sansar 55.6 57.5 N14 5 buudal No Data 55.75 2009 based on 5 months morning and evening data 2010 based on 2 months morning and evening data Mongolian National Noise Standards: MNS 2007-4585 allowable limits; daytime is 60 dB, night is 45 dB. Night is 10pm-6am according to the Act on Labor. Source: Central Laboratory of MET.

117. WHO10 states that guidelines on community noise (not industrial work place noise, therefore including traffic) should be based on the following:

a. Indoor sound levels, thresholds for guidelines should be based on a combination of values of 30 dB (average equivalent over 8 hours LAeq) and 45 dB (maximum for an individual noise event); b. Outdoor sound levels should not exceed 50 dB LAeq to protect the majority of people from being moderately annoyed during the daytime. Most countries in Europe have adopted 40 dB LAeq as the maximum allowable level for new developments; c. Hospital patients have less ability to cope with stress, the equivalent noise level should not exceed 35 dB LAeq in most rooms in which patients are being treated or observed; and d. Schools the background sound pressure level should not exceed 35 dB LAeq during teaching sessions.

118. It is clear from the noise measurements in Ulaanbaatar that in the majority of locations, ambient noise exceeds the WHO recommendations for community noise outside. However, with regards to the noise within sensitive receptors such as households, schools and hospitals, the data are of limited value as the distance from the source is not given and measurements are not taken within buildings.

119. Climate change. In order to address the issue of global climate change and its effects on people and the economy, Mongolia affirmed the United Nations Framework Convention on Climate Change (UNFCCC) in 1993 and the Kyoto Protocol in 1999. The GOM has taken considerable steps toward the implementation of the UNFCCC, by accomplishing the required commitments such as the Initial National Communication, Technology Needs Assessment and the National Action Plan on Climate Change to address climate change and other legal commitments.

th 120. In 2007, Mongolia was ranked 96 in the list of CO2 emitting countries, contributing

10 World Health Organization. 1999. Guidelines on Community Noise. Available at: http://www.who.int/docstore/peh/noise/guidelines2.html. 40

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

around 0.04% to the global emission11. UNEP12 states that in Mongolia, the energy sector (including stationary energy, transportation and fugitive emissions) was the largest source of greenhouse gas (GHG) emissions comprising 65.4% of total emissions. The second largest source of GHG emissions was the agricultural sector (41.4%). The report also states that total CO2 removal was more than total CO2 emissions in 2006 due to an increase in the area of abandoned lands and a reduction in newly cultivated land. However, by 2020, it is predicted that Mongolia’s GHG emissions will be more than 5 times that of 2006.

121. Climate modeling for Mongolia is projecting changes which include increased air temperatures, increased precipitation in some areas and a reduction of water resources in other areas.13. Potential evapo-transpiration increase would be higher than precipitation amount increase. Future climate changes are expected to negatively impact Mongolia, mostly in the agricultural and livestock sectors. This in turn will affect the society and economy, meaning climate change adaptation is a significant issue for the country.

122. Natural disasters. Natural disasters in Mongolia are mainly caused by forest fires, floods, extreme cold, snow storms and disease outbreaks. Forest fires accounted for 49% of the disaster events during the period 1990 - 2000. During this period, floods, disease outbreaks and extreme cold and snow storms accounted for 11%, 13% and 5%, respectively14. Floods and earthquakes are the natural disasters of potential relevance to the project and thus further discussed below.

123. Earthquakes. Mongolia has experienced four major earthquakes (Ms>8) and many more moderate earthquakes (Ms 5.3-7.5) in the last century. The seismic activity in Mongolia is related to its location between the compressive structures associated with the collision of the Indian-Australian plate with the Eurasian plate on the one hand and the extensional structure associated with the Baykal rift system on the other. The historical records (1903 onward) of the seismicity in Mongolia show a high concentration of seismic activity along the Mongolian-Altay and Gobi-Altay ranges and the north western border with Russia and around Mogod east of Hangay mountain. The multi-organizational Global Seismic Hazard Assessment Program classifies Ulaanbaatar as low to moderate earthquake risk areas shown in Figure 12.

Figure 12: Seismic Risks in Mongolia and the PRC

Source: Global Seismic Hazard Assessment Program. Global Seismic Hazard Map

11 United Nations Statistics Division, Millennium Development Goals Indicators. Available at: http://mdgs.un.org/unsd/mdg/SeriesDetail.aspx?srid=749&crid= 12 United Nations Environment Program. 2009. Mongolia: Assessment Report on Climate Change 2009. 13 Ibid. 14 Source: National Center for Emergency, 2002. 41

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

124. Flooding. Localized flooding can be caused in most areas of the country, especially in built-up areas through heavy rain events because of poor surface water drainage. This flooding is ephemeral, and the water subsides rapidly. More than 75% of precipitation in Ulaanbaatar occurs in July and August. Serious floods, mainly caused by the Tuul River, occurred in 1915, 1939, 1959, 1966, 1967, 1971, 1973, 1982 and 2003. In 1966, the Tuul water level reached 3.2 meters with a flow of 1500-1800 cubic meters per second and the flood killed over 100 people. Figure 13 shows flood prone areas of the City. The new Songinohairkhan district hospital supported by the project is not located in flood prone areas.

Figure 13: Flood Prone Areas of Ulaanbaatar

Source: JICA Study on Ulaanbaatar City Master Plan. ‘Flood Prone Area’ map. (2009)

5.2. Ecological Resources

125. Ecological resources of the potentially impacted environment are defined to include the area’s flora and fauna, and specially protected areas. The project site includes the new Songinohairkhan district hospital and it has very little vegetation or exposed ground which may form habitats for fauna. However, there are a limited number of bird species observable in the city, such as crows and sparrows, common to many urban environments. The project will not encroach on legally protected sites; the closest protected site is the Gorkhi Terelj National Park. This park is outside the city and not within the project’s area of influence. There are no rare, threatened, or endangered species within the construction boundaries of the replacement Songinohairkhan district hospital.

5.3. Socio-Economic Conditions

126. Population. The population of Ulaanbaatar, the capital city of Mongolia, has been increasing rapidly from 0.78 million (Mongolia: 2.40 million) in 2000 to 1.46 million (Mongolia: 3.17 million) in 2017 with an average annual growth rate of 2.65%. This rapid increase of population is chiefly due to a rapid migration from rural area to urban area. The average number of populations migrated in the past 10 years is estimated at around 20,000 per year which cause the expansion of Ger area surrounding the apartment area of Ulaanbaatar. At 42

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

present Ulaanbaatar accounts for 45.3% of the total population of Mongolia. The projected urban population of 2030 is 1.87 million or 1.28 times larger than the population in 2017.

127. Economy. The economy of Mongolia has grown rapidly at average annual growth of around 5.6% and transition to market economy has proceeded at remarkable speed as well. The economic growth has been pushed by increased international commodity price as well as expansion of copper output until the global financial crisis occurred in 2008. Meanwhile, the regional domestic production of Ulaanbaatar City accounts for around 56% of the National gross domestic production (GDP), as the city has historically been the centre of the economy as well as of the administration.

128. In Mongolia, mining and quarrying are the biggest financial contributors to industrial output (58%) with manufacturing second (32%). The Tavan Tolgoi area is the world's largest untapped coking coal deposit. Manufacturing includes metals (such as copper and steel foundries) as well as woolen products such as cashmere and carpets. Ulaanbaatar has some manufacturing plants but is also the base for offices of international and national companies; because of the current infrastructure constraints, it is considered difficult to operate a significant and effective business outside Ulaanbaatar.

129. Unemployment. According to the Mongolian Statistical Yearbook 2017, the ‘Registered Unemployment Rate’ for Ulaanbaatar is 1.3%. However, this is the rate of people that are officially registered unemployed. The book also provides an ‘unemployment rate’ which is 7.5% for the City, derived from a new methodology of calculation based on the results of a Labor Force Survey.

130. Poverty. The Mongolian Statistical Yearbook 2017 provides background data on poverty levels within the City. The Poverty Headcount Index is a widely used poverty measure, giving the percentage of the population whose consumption is below the poverty line. For Ulaanbaatar, this rate is 24.8% in 2017, which compares to 26.6% nationally. This increases to over 34.9% in rural areas, showing that relatively speaking, Ulaanbaatar is wealthier than the rural areas. This translates to an average household income of nearly 1,117,921 MNT in urban areas, and 885,891 MNT in rural areas.

131. Ethnic minorities. Ethnic Mongols account for about 85% of the population and consist of Khalkha and other groups, all distinguished primarily by dialects of the Mongol language. The Khalkha make up 90% of the ethnic Mongol population. The remaining 10% include Buryats, Durbet Mongols and others in the north and Dariganga Mongols in the east. Turkic peoples (Kazakhs, Tuvans, and Chantuu (Uzbek) constitute 7% of Mongolia's population, and the rest are Tungusic peoples, Chinese, and Russians. Most but not all Russians left the country following the withdrawal of economic aid and dissolution of the Soviet Union in 1991.

132. Public Health. The MON: Fourth Health Sector Development Project – Second Additional Financing builds on hospital sector reforms initiated under previous ADB funded operations in Mongolia. ADB sector recommendations emphasize the need for structural changes in health care delivery by rationalizing excess hospital capacity at the secondary and tertiary levels, particularly in Ulaanbaatar. The project will deliver tangible benefits to women by ensuring higher safety standards to protect female staff against hospital acquired infections (HAI) and improving safety of blood transfusions in hospitals. The MON: Fourth Health Sector Development Project – Second Additional Financing will provide benefits to Ulaanbaatar but also provide a catalytic role in the reform of the hospital sector in Mongolia.

133. Occupational Health and Safety. Occupational safety considerations are currently a low priority. Construction workers, laborers, maintenance staff etc can frequently be observed operating without Personal Protective Equipment (PPE) to reduce the likelihood of an injury at work. Observed examples include using oxy-acetylene torches without gloves or goggles, construction workers without hardhats and safety boots. Article 16 of the National Constitution 43

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of Mongolia states that every employee has the right to ‘suitable conditions of work’. The government adopted a National Program for Occupational Safety and Health Improvement in 2001 and national standards are also adopted such as the National Standard on Occupational Health and Safety MNS 5002:2000. Mongolia recently banned the use of asbestos building products, but the management of asbestos containing materials (ACM) remains fairly poor.

134. Community Safety related to Construction. Ulaanbaatar has many construction sites, some of which operate 24 hours a day. Mongolian standards currently establish a maximum environmental noise goal for residential receptors of 60 decibels (A-weighted) (dB(A)) during the daytime and 45dB(A) during the night time, with night being defined as between 22:00-06:00 hours. Depending on noise attenuation and proximity to the construction works, 24 hour a day construction may breach the National Standard for Noise (MNS 4585:2007). In addition, when construction work takes place in a public environment, safety measures are often lacking to protect the public.

135. Physical cultural resources. Ulaanbaatar is rich in physical cultural resources. Famous sites are located in the Historical and Cultural Conservation Zone, defined in the Policy Zone map of the Ulaanbaatar City Master Plan. The replacement Songinohairkhan district hospital and the new Central Laboratory are not located within the Conservation Zone. No physical cultural resources were registered within the two project sites.

5.4. Sensitive Receptors within the Project’s Area of Influence

136. The potentially affected environment in the project area is defined principally in regard to two factors: (i) the nature and scale of the proposed action; and (ii) the sensitivity and circumstances of the environment in which the proposed action will occur or issues of special concern (such as induced and cumulative impacts, etc.). The project’s area of influence regarding potential impacts associated with noise and traffic congestion during construction will extend to areas around the construction zones. 137. The Songinohairkhan hospital is located in Ulaanbaatar. There are no physical- geological and hydro-dynamically difficult conditions that may adversely impact the construction, and there is a low earthquake potential. No environmentally sensitive areas were observed near the sites as all infrastructure improvements are located in Ulaanbaatar City. There are no cultural heritage sites in the project areas.

5.4.1. Songinohairkhan Hospital

138. The affected area for the Songinohairkhan hospital is shown in Figure 14 which was used as guide for the public consultation program.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Figure 14: Songinohairkhan Hospital Affected Area Map

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

6. ANALYSIS OF ALTERNATIVES

139. An analysis of alternatives was conducted to justify the project based on a “with and without-project” scenarios. Component-specific alternatives assessed in the framework of this updated IEE included (i) alternative site plans and layouts for the replacement SDH; (ii) technical design of the replacement SDH; and (iii) hazardous and medical waste treatment options. The different alternatives considered are discussed below.

140. The project will replace a district hospital with a modern multi-functional facility in the structural components and will generally improve healthcare and drug management in all activities. The no action alternative would result in continuation of the poorly functioning district hospital and not provide a model for improved hospital management for all of Mongolia.

141. The “with-project” alternative will improve patients’, hospital workers’ and citizen safety in hospitals in Mongolia. The design of each subproject was formulated based on an assessment of alternative solutions. The recommended site and layout for the subproject were selected from various alternatives so as to minimize adverse impacts on the environment and land resources.

142. Alternatives for medical waste management at the hospital are restricted to on-site storage systems, since the new centralized medical waste treatment system at the Naran Enger Landfill (run by MOH-licensed Company) is very near the hospital, and both the hospital and Ambulatory 1 now have contracts with the MOH-licensed Company for this waste collection and treatment. This is the prescribed medical waste treatment system by the MOH and Ulaanbaatar City. In addition, the new hospital will construct waste management systems in compliance with MOH Orders 158, 179 and 380 of 2011. For the medical gas storage and generators buildings, the site was selected proximity to the existing utility systems for electricity and heating within the SDH premises, around 20 meters west from the existing district hospital. The selected location is in full compliance with the Guidelines on Production, Transportation and Storage of Healthcare Related Gases by Joint Order No: A/172/167 of Minister for Health, Minister for Social Welfare, and Minister for Infrastructure in 1998 and the “Requirements for pressurized gas cylinders and safety regulation” Minister of Energy, 04 December, 2007, Order 93, which also included in the pressurized gas storage requirements in the country.

143. Several alternative configurations and site layouts have been produced for the new hospital and the selected site allows for the optimal use of the available land to provide the required areas for the hospital, parking and greening of the site. In addition, the access plan provides the needed multiple access points for the new hospital and good circulation within the site for the hospital and other facilities.

144. Alternatives for hazardous waste management at the Songinoharikhan Hospital are also limited to on-site storage systems, since there is currently no centralized hazardous waste treatment facility. A double containment system with specific design criteria has been recommended in the IEE.

145. The facility is served by centralized systems for water supply, wastewater collection and treatment, heat and electricity so no alternatives were evaluated.

7. ANTICIPATED ENVIRONMENTAL IMPACTS AND MITIGATION MEASURES

7.1. Screening and Avoidance of Environmental Impacts

146. The potential environmental effects of the Project have been scoped beginning with 46

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the Rapid Environmental Assessment (REA) during project preparation, and subsequently through PPTA assessments and feasibility study reports. The major potential environmental impacts have been identified for each component and are presented below. While the full range of potential environmental effects will be discussed in this chapter, these impacts and the measures to avoid or ameliorate them will be the main emphasis.

147. Component 1: The Songinohairkan Hospital. Adverse environmental impacts due to civil works will be minimal, of short duration, and mitigated by design and project management of facilities construction. There may be relocation and removal of existing trees and plants during the construction period, but trees around the project components will be replanted and other vegetation restored. Several smaller buildings must be demolished for the project and this will cause a considerable amount of construction waste for disposal in nearby Naran Enger landfill.

148. The new Songinohairkan Replacement Hospital will be connected to the Ulaanbaatar centralized systems for water supply, wastewater collection, electrical supply and heating systems, as is the situation with the existing hospital. The main potential impact during operation relates to waste management.

7.2. Positive Impact and Environmental Benefits

149. The expected impact of the MON: Fourth Health Sector Development Project – Second Additional Financing will be to improve the health status of the Mongolian population, including the poor. The outcome will be improved health sector efficiency, governance, and drug safety. The project will directly benefit over 250,000 mostly poor residents of the Songinohairkhan District of Ulaanbaatar by improving district hospital services. The project will also benefit the entire population of Mongolia by improving access to safer drugs, and in the long run, improve allocative efficiency in the health sector by optimizing the use of hospital services and improve return on future investment in the hospital sector. Improving both the country’s health services and the health status of the population will lead to a reduction in household expenditures and time spent seeking medical care. The poor will benefit particularly from the project’s drug safety activities as they are currently more likely to purchase and consume substandard pharmaceuticals.

150. Other benefits of the new Songinohairkhan hospital include: • Complex health service provided to the Songinohairhan district population; • Hospital activities enhanced and second category of clinic service will be served; • Hospital with world class consistent organizational structure; • A new delivery and surgery unit so citizens do not need to travel to the district hospital; • Opportunity to improve access situation and develop multiple accesses for various users and allow customers to enter the hospital freely, also patients can enjoy comfortable environment of standard greenery area around the hospital.

151. The impact of the project will be improved quality of health services in Mongolia. The outcome will be improved patient health and health workers safety in hospitals in Mongolia. This will be done through implementation of a model multi-functional hospital, strengthened medical training and improved drug regime for the country. The project geographic focus is in Ulaanbaatar but it benefits the entire country.

7.3. Environmental Impacts and Mitigation Measures During Construction

152. The following impacts and mitigation measures refer to construction impacts which are mostly common to the MON: Fourth Health Sector Development Project- Second Additional Financing Component, the new Songinohairkan Hospital. Thus, this updated IEE focuses on anticipated impacts during construction of the new Songinohairkan Hospital. Construction will 47

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require soil erosion protection, dust and noise control as well as management of the impacts from machinery operation, transport and haulage of materials and measures to ensure occupational and community health and safety. There are a few site specific requirements.

7.3.1. Physical Impacts

153. Impacts on Soil. Three types of potential impacts on soil include: (i) soil erosion; (ii) soil contamination; and (iii) inappropriate management of spoil disposal. a. Soil erosion. May be caused by construction, excavation of pipe trenches, and borrow pits, stockpiles and spoils from earthwork during construction of buildings, roads, and grading. The factors that are expected to contribute to accelerated erosion in the project area are winds and rainfall, especially during the rainy months of May to August. If erosion prevention measures described below in the construction phase are implemented, no significant impacts on soils are foreseen. b. Soil contamination. Contamination of soil in the construction phase may result from the inappropriate transfer, storage, and disposal of petroleum products, chemicals, hazardous materials, liquids and solid waste. c. Spoil disposal. Significant spoil disposal will not be required for the new Songinokhairkan Hospital, and potential impacts would be short-term and localized.

154. Mitigation of impacts on soil. The construction site for the new Songinohairkan Hospital is relatively small and the impacts on soil will be mitigated through a number of remedial measures which are defined in the EMP, which was incorporated in the bid documents and construction contracts: a. Soil erosion: Soil erosion management plan to be updated by the contractor based on latest site plan and to be approved by the Ulaanbaatar City and PIU. Since disturbed areas will be relatively small, the plan can be an overlay to the site plan showing how runoff will be controlled at site perimeter to control soil and water runoff, and how disturbed areas will be reclaimed. b. Soil contamination: (a) store chemicals/hazardous products and waste on impermeable surfaces in secure, covered areas; (b) remove all construction wastes from the site to approved waste disposal sites; (c) establish emergency preparedness and response plan (emergency preparedness & response plan including Spill Management Plan was prepared by the Contractor); (d) Provide spill cleanup measures and equipment at each construction site; and (e) Conduct training in emergency spill response procedures.

155. Mitigation of impacts on surface and groundwater. There are no surface waters near the project site. As groundwater near the new Songinohairkhan replacement hospital is generally relatively deep (>4m), no impacts to groundwater resources are anticipated in either the construction or operation phases of the project. The major risk to groundwater resources is pollution through spills of dangerous substances, and inappropriate construction waste management. The potential risks to groundwater will be mitigated through a number of activities defined in the EMP, and which incorporated in the bid documents and construction contracts: a. Develop and implement contingency plans for control of oil and other dangerous substances (Spill Management Plan); b. Construction wastes and materials (e.g. fuel) will be properly controlled and maintained during construction. Wastes will be removed from two project sites and taken to approved disposal facilities; c. Water collection basins and sediment traps will be installed in all areas where construction equipment is washed; d. Effective wastewater collection system to discharge to central sewerage system at the new Songinohairkan Hospital.

156. Impacts on air quality. Minor temporary air quality impacts during the construction 48

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stage could be anticipated due to fugitive dust generation in and around the new Songinohairkhan hospital. Minor increases in the level of nitrogen oxides (NOx) and sulphur oxides (SOx) from construction plants and machinery are expected. These construction phase impacts will be localized and temporary, but could affect nearby residential areas, as well as the existing hospital. The potential impacts on air quality will be mitigated through a number of activities defined in the EMP. At the Songinohairkhan hospital, a new asphalt access road and a perimeter fence will be constructed prior to construction, to minimize dust generation through blocking of wind as shown in Figure 15. The civil works contract documents will specify that: a. Water will be sprayed on construction sites and material handling routes where fugitive dust is generated; b. Effective dust suppression measures will be implemented near sensitive receptors such as schools, hospitals, or housing; c. Fuel and chemicals will be covered / stored to minimize emissions; d. Trucks carrying earth, sand or stone will be covered with tarps or other suitable cover to avoid spilling; e. Construction vehicles and machinery will be maintained to a high standard to ensure efficient fuel-burning (note that local standards do not exist for vehicle emissions); f. Air quality monitoring will be undertaken around the new Songinohairkhan hospital to confirm impact of project in accordance with the environmental monitoring plan.

Figure 15: Example Construction Zone Perimeter Fence

without pedestrian protection roof (N, S, W)

with pedestrian protection roof (east)

157. The proposed construction zone perimeter fence will have a pedestrian protection roof on the eastern side facing the public street. The fence will be at least 2m high and be able to bear wind and the roof must bear snow load and falling debris. The perimeter fence will have supplemental benefits on noise diffusion and public safety.

158. Solid waste management. Inadequate disposal of construction wastes could have adverse impacts on the soil, water and health of laborers and the community. Wastes streams will include inert construction wastes (soil, debris, concrete etc.), municipal type wastes (construction workers’ food and packaging wastes from construction consumables) and 49

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hazardous wastes (fuel containers, oil filters, oily rags etc.) In addition, the disposal of the existing hospital and other small buildings will create another source of construction debris for disposal at the nearby Naran Enger landfill.

159. It is necessary for the existing hospital to organize a temporary medical waste storage room in the interim period until the new hospital is operational. A room has been identified in the hospital and this room needs to be carefully isolated from other hospital uses and staff.

160. Four small structures, the abandoned underground water reservoir for the Songinohairkhan project have been demolished in 2016. The estimated waste material from the first phase of demolition was approximately 4,630 tons.

161. The existing Naran Enger landfill will receive all solid waste from the new Songinohairkhan hospital including small buildings. This landfill was designed by JICA in 2006-2007 to international standards, and an Environmental Impact Assessment was approved by MET in 2006. The facilities of Naran Enger landfill constructed in Phase 1 included the site offices, the landfill area, a leachate treatment facility (pond), a recycling complex (a sorting yard), and garage. The site comprises of an area of approximately 20 ha. The disposal site is to be expanded to approximately 82 ha in total in future. According to the operation plan, the 82 ha site will be developed in seven phases.

162. If asbestos containing materials are suspected in the demolition of buildings, the contractor must consult with the PIU and MET, determine if the potential ACM is friable or non-friable asbestos, and develop an appropriate ACM control plan. If friable asbestos is contained in the structures, it may be necessary to subcontract the removal to a specialty firm who can follow international best practices for isolation, negative pressure containment and specialized PPE. During the demolishment of small structures, it was reported that no asbestos were found.

163. The potential impacts arising from solid waste production and disposal will be mitigated through a number of activities defined in the EMP for the new Songinohairkan Hospital, and which incorporated in the bid documents and construction contracts: a. Storage and containment: Provide appropriate waste storage containers for worker’s construction and hazardous wastes; Install confined storage points of solid wastes away from sensitive receptors, regularly haul to an approved disposal facility; b. Use of contractors: Use licensed contractors to remove wastes from two project sites; Hold contractors responsible for proper removal/disposal of any significant residual materials, wastes/contaminated soils that remain on the ground after construction; Develop plan for removal and disposal of small buildings including ACM handling and disposal plan of found.

164. Noise. The major sources of noise pollution are movement of construction vehicles, the haulage of construction materials to the construction site and the noise generating activities at the site itself. Concrete mixing and material movements are the primary noise generating activities and will be uniformly distributed over the entire construction period. Construction activities are expected to produce noise levels in the range of 80-95 dB(A). The major works will be carried out during daytime. The noise produced during construction will however not have significant impacts on the existing ambient noise level. Noise levels might be elevated, but they will be temporary and localized, and largely in line with background noise levels. The potential noise impacts will be mitigated through a number of activities defined in the EMP for the new Songinohairkan Hospital, which incorporated in the bid documents and construction contracts: a. Source control: Maintain all exhaust systems in good working order; undertake regular equipment maintenance; b. Locate sites for concrete-mixing and similar activities as far as possible from sensitive areas; 50

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c. Operate between 6am-10pm only and reach an agreement with nearby hospital and residents regarding the timing of heavy machinery work, to avoid any unnecessary disturbances; d. Monitor noise at sensitive areas at regular intervals (as defined in monitoring plan); e. Seek suggestions from community members to reduce noise annoyance. Public notification of construction operations will incorporate noise considerations; information procedure of handling complaints through the GRM will be disseminated; and Temporarily move at-risk individuals (patients treated in hospital) to less impacted section of the existing hospital.

165. For the proposed new Songinohairkhan hospital, Figure 16 is a map of construction work impact zone maximum distance showing where noise pollution levels (NPL) meet health standards. The acoustic problem zones radius is 30-100 m and it is within populated zone radius (nearest distance from construction zone to populated zone is 20 m). In middle intensity zone around 100 households will be disturbed including households which will live in building which is constructed now and will be in use after 2 years. Although not a noise barrier per se, the proposed perimeter fence will diffuse some construction noise at ground level.

Figure 16: Noise Impact zones during construction

7.3.2. Biological Impacts

166. Flora and Fauna. Field investigations have established that there are no threatened or endangered flora and fauna species within the project’s direct area of influence. The new Songinohairkhan hospital will be re-vegetated after construction with grasses and shrubs appropriate to Ulaanbaatar environment.

7.3.3. Socio-economic Impacts

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167. Involuntary resettlement and indigenous peoples. According to latest site planning, the government proposed to increase the space for additional parking area and to build second access road around the old hospital by freeing land on the western side on the SDH site. Based on the census and preliminary inventory of lost assets carried out in March 2019, a total of 16 plots will be affected (2,013 m2 licensed and 1,400 m2 unlicensed land). Of the 21 households, 8 of them have houses or gers and will be required to relocate. The funding for the resettlement is included in the 2019 budget of UCMO and could occur in May 2019. The project is categorized B for involuntary resettlement. Land Acquisition and Resettlement Plan has been prepared. The government will be responsible for the resettlement of the households in accordance with ADB’s policies and guidelines on involuntary resettlement (ADB Safeguard Policy Statement, 2009). The project is classified as category C for indigenous peoples. The assessment determined there will not be any negative impact on indigenous peoples.

168. Risks to community health and safety. The new Songinohairkhan hospital construction site will be located close to residential and commercial urban areas, representing a threat to public health and safety. The project may also contribute to road accidents through the use of heavy machinery on existing roads. The potential impacts on community health and safety will be mitigated through a number of activities defined in the EMP. The contractors will implement the following measures: a. Traffic management. A traffic control and operation plan will be prepared, and it shall be approved by the PIU and Ulaanbaatar District Architect prior to any construction at the new Songinohairkhan hospital. The plan shall include provisions for diverting or scheduling construction traffic to avoid morning and afternoon peak traffic hours, regulating traffic at road crossings with an emphasis on ensuring public safety through clear signs, controls and planning in advance; b. Construction sites. Clear signs will be placed around the construction site in view of the public, warning people of potential dangers such as moving vehicles, hazardous materials, and excavations and raising awareness on safety issues. Heavy machinery will not be used after 10PM-6AM and all such equipment will be returned to its overnight storage area/position before night. The site will be made secure, discouraging access by members of the public through appropriate fencing whenever appropriate; c. Medical gas cylinder storage. Pressurized oxygen, anesthetic (N2O) and CO2 gases used for medical purposes. There are two types of hazards associated with medical gas equipment: general fire and explosions, and mechanical issues such as physical damage to compressed gas cylinders. Storage of medical gas cylinders must be stored in a separate building as required by GASI. The storage building shall be designed in compliance with relevant national design standards and codes for medical pressurized gases, including but not limited to: Guidelines on Production, Transportation, and Storage of Healthcare Related Gases by Joint Order No: A/172/167 of MOH, Minister for Social Welfare, and Minister for Infrastructure in 1998, “Requirements for Pressurized Gas Cylinders and Safety Regulations” Minister of Energy, 04 December, 2007, Order 93, and MNS 0640: 1989 Fire safety requirements. Prior to construction, contractors shall secure approval from relevant authorities for the proposed building design, location and fire safety requirements

169. Occupational health and safety. The civil works contractors will implement adequate precautions to protect the health and safety of construction workers at the new Songinohairkan Hospital. The occupational health and safety risks will be managed by applying measures in the following order of preference: avoiding, controlling, minimizing hazards, and providing adequate protective equipment. The contractors will undertake the following activities: a. Environmental, Health and Safety Officer. Each contractor will appoint an Environmental, Health and Safety Officer (EHSO) to implement and supervise the Environmental, Health, and Safety Management Plan; b. Environmental, Health and Safety Management Plan (EHSMP). Each contractor 52

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will prepare a HSMP for the construction workers on the basis of the EMP. It will be submitted to the PIU for review and appraisal. The detailed EHSMP will include the following provisions: i. Clean water. Provide a clean and sufficient supply of fresh water; ii. Sewage and wastewater. Provide an adequate number of latrines and other sanitary arrangements at the site and work areas, and ensure that they are cleaned and maintained in a hygienic state; iii. Solid waste. Garbage receptacles at construction site, which will be periodically cleared to prevent outbreak of diseases will be setup; iv. Personal protection. Provide personal protection equipment (PPE), such as safety boots, helmets, gloves, protective clothing, goggles, and ear protection, in accordance with relevant health and safety regulations, for workers; v. Emergency Preparedness and Response. An emergency response plan to take actions on accidents and emergencies, including environmental and public health emergencies associated with hazardous material spills and similar events will be prepared, and submitted to the PIU for review and appraisal. A fully equipped first-aid base at each construction site will be organized; vi. Records Management. A Records Management System that will store and maintain easily retrievable records protected against loss or damage will be established. It will include documenting and reporting occupational accidents, diseases, and incidents. The records will be reviewed during compliance monitoring and audits. vii. Safety communication. Ensure that safety, rescue and industrial health matters are given a high degree of publicity to all persons regularly or occasionally on the site. Posters in Mongolian drawing attention to site safety, rescue and industrial health regulations will be made or obtained from the appropriate sources and will be displayed prominently in relevant areas of the site; viii. Training, awareness and competence. Train all construction workers in basic sanitation and health care issues, general health and safety matters, and on the specific hazards of their work. ix. ACM contaminated building materials (if any). Preparation of an ACM handling and disposal plan (see below)

170. Other construction mitigation measures for potential health and safety issues during construction are as follows (with referenced Mongolian standards): a. Construction workers shall strictly observe the Rules of occupational safety and safe operations БНбД 12-04-06 (2006), БНбД 12-03-04 (2006), and the fire safety rules БНбД 2.01-03-92, БНбД 2.01.02-85, БНбД 2.08.02-89 and БНбД 41-01-02; b. Construct a perimeter fence to protect work camp from non-authorized entrances (see detail in air quality section); c. Install health and safety sign board; d. Install a lightning arrester according to Instructions of development of drawings of lightning protection of facilities БН-305-77 constructed according to Electric technical work БНбД 3.05.6-90; and e. Provide fire protection equipment and develop a fire prevention plan.

171. Asbestos contaminated construction debris. There is a possibility that asbestos containing materials (ACM) may be exposed during the deconstruction works. Although asbestos poses a risk to human health, building systems such as roofing and tiles that are non-friable (i.e. difficult to become airborne) are the lowest risk category of asbestos fibers. If any potential asbestos materials are encountered during deconstruction works, an ACM handling and disposal plan will be developed. The plan will include specific PPE requirements, wrapping of the non-friable ACM (note that disturbing friable asbestos is considered extremely unlikely and would require a much more sophisticated plan), temporary storage, transport and disposal of the ACM. Annex 3 contains general guidance for managing ACM, if discovered. 53

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172. Utilities provision interruption. At the new Songinohairkhan hospital site, construction will require relocation of local municipal utilities such as heating, electricity, water, sewerage and communication cables. Temporary suspension of services (planned or accidental) can affect the economy, industries, businesses and residents’ daily life. The potential impacts on utilities provision will be mitigated through a number of activities defined in the EMP, to be incorporated in the bid documents and construction contracts: a. Contractors will assess potential disruption to services and identify risks before starting construction; b. If temporary disruption is unavoidable the contractor will develop a plan to minimize the disruption and communicate the dates and duration in advance to all affected people, in conjunction with new Songinohairkhan replacement hospital. c. Relocation of central heating lines accomplished during summer months to prevent outages of heat in cold months.

173. Other Social Issues. No other social risks and/or vulnerabilities are anticipated as a result of the project. The project construction workers will be engaged locally. Civil works contracts will stipulate priorities to (i) employ local people for works, (ii) ensure equal opportunities for women and men, (iii) pay equal wages for work of equal value, and to pay women’s wages directly to them; and (iv) not employ child or forced labor.

7.4. Environmental Impacts and Mitigation Measures during Operation

7.4.1. Component 1: Songinohairkhan District Hospital

174. Water Supply. The new hospital will be connected to the UB central water supply system. The hospital will be a much larger and more modern hospital facility and will require significantly more potable water from the UB central water supply system. It is recommended that the hospital install water saving fixtures, have a water saving campaign and install a proper water meter so that hospital pays for actual water use.

175. Wastewater. Wastewater generated by the SDH will be collected in the central sewerage network and treated at the Ulaanbaatar municipal WWTP. The hospital should install proper wastewater neutralization facilities to neutralize the wastewater prior to discharge to sewerage system in accordance with MOH Orders 158, 179 and 380.

176. Heating and Electrical Backup System. The new hospital should be designed with a backup system for heating and electrical supply in the case of emergency outages of the central supplies. This was identified as a problem area in the existing hospital.

177. Hazardous waste. As in the case with all Ulaanbaatar hospitals, small quantities of hazardous, solid and liquid chemical and pharmaceutical waste (including cytotoxic waste) are produced in hospital operations. The proposed ADB Fifth Health Sector Project will be adding a storage and treatment system for such wastes at the nearby Central Medical Waste Treatment Facility at the Naran Enger Landfill. As such, the Songinohairkhan hospital will only need to store these materials on-site for a short period, until this new system is operational and later will be able to transfer these hazardous wastes directly to the central treatment facility along with medical wastes.

178. Solid waste. Solid wastes will be generated according to MOH regulated hospital waste categories such as: normal, special, hospital service, chemical and heavy metal contaminated. Infectious waste is not generated currently but it will be generated after MON: Fourth Health Sector Development Project – Second Additional Financing planned hospital replacement and other types of waste generation will also increase. The hospital and Ambulatory 1 have existing contracts with solid waste hauling companies to collect their normal solid waste and transport it to the nearby Naran Enger landfill.

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179. Medical waste. The quantity of medical wastes produced at the new Songinohairkhan hospital will greatly expand in the new facility from current operations. The design of the new hospital will be in full compliance with MOH Order 158 for management of medical waste in all hospital operations, and MOH Order 179 for the design of the medical waste storage system. Figure 17 shows current collection of medical waste at the hospital by the MOH- licensed medical waste collection and treatment company.

Figure 17: Collecting the hospital hazardous waste for disposal by MOH-Licensed Medical Waste Company

180. Table 11 outlines the waste production characteristics and disposal path at the SDH, illustrating the current and future estimated production after implementation of the MON: Fourth Health Sector Development Project – Second Additional Financing. Future waste generation was based on increasing the existing quantities by a factor of 1.7 based on a ratio of the existing versus proposed hospital size. The hospital is located very near to the existing Ulaanbaatar central medical waste treatment facility and the MOH-licensed treatment company has a contract to collect medical wastes and treat at this facility.

181. In addition, the proposed ADB Fifth Health Sector Project will improve the treatment capacity of the UB central medical waste facility and install a system to neutralize or recycle hazardous chemicals from UB hospitals. As such, this improved system should be available for the new Songinohairkhan hospital nearly at the same time as the hospital is completed, so these hazardous chemicals can be stored for a short period only, and in the future, they will be collected by the MOH-licensed medical waste treatment company.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Table 10: Generation of Wastes from Songinohairkhan Hospital № Category1 Packing Covered material Packing types in Current Quantity Estimated Future Disposal requirement hospital Generated Quantity Based on 1.7 times Existing Wastes from office room, service room, To move centralized Normal By standard 6 ton/year normal 10.2 ton/year normal 1. Black pack warehouse, canteen, corridor and hospital disposal point of Naran waste requirement waste waste outside area. Enger Landfill Wrapping materials such as sterilization paper, Intravenous infusion Intravenous infusion Water – proof cotton, Feces, blood, mucosa, disposable plastic system 293-328 system 498-558 UB Central Medical Infectious By standard 2. and durable tools and utensils, mirror, gloves, system, hat, p/month, Gloves 529- p/month, Gloves 900- Waste Treatment waste requirement yellow bag mask, used sheet and other wastes of medical aid 950p/month, Vacuum 1530p/month, Vacuum Facility and service. tinier 110-155p/month tinier 187-264p/month 3gr syringe 3789- 3gr syringe 6440- 8181p/month,10gr 13908p/month,10gr syringe 596- syringe 1013- Waste with Syringe, blood sample needle, ampoule, blade of By standard 652p/month, 20 gr 1108p/month, 20 gr 3. sharp pin Safe box knife and broken glass requirement syringe 261- syringe 444- and blade. 283p/month, Vacuum 481p/month, Vacuum tainer needle 97- tainer needle 165- 147p/month 250p/month Bio preparation, medicine, vaccine, narcotic substance, substance container, ampoule, glass and Waste of box which storage term expired, prohibited to use, Temporarily store on medical damaged and polluted. Laboratory solid and liquid Size generated is Size generated is site until Fifth Health By standard 4. and Brown pack waste of treatment, diagnosis, research, cleaning, uncertain, difficult to uncertain, difficult to project improves UB requirement chemical disinfection (reagent, chemical waste), solution, determine determine Central Medical Waste substance solvent, solution to be used and processed in Facility radiology, formaldehyde, ethanol oxide, chemical substance which expired term. Yellow liquid Body tissue of surgery and dissection, amputated Pathogenic UB Central Medical 5. and durable body and tissue, cancer tissue, fetus and miscarried -3- - wastes Waste Treatment bag fetus Waste which derived from tuberculosis, naturally Waste with focused infectious disease and sexually transmitted Water – proof high disease being held by International Health Regulations It is not available to UB Central Medical 6. and durable -3- - infectious and laboratory wastes (alive pathogenic micro foresee waste scope Waste Treatment red bag risk2 organisms in tissue and cell culture, microbiological culture, its equipment) Temporarily store on Waste of Locked in Thermometer glass, pressure apparatus, site until Fifth Health 7. heavy durable bin medical equipments, luminescent light and -3- - project improves UB metal and container battery Central Medical Waste Notes: 1 According to MOH guideline “Implementation of hospital waste management” 2 Currently not generated but will be generated after planned activities 3 According to the standard, these wastes should be classified into red bag or box and kept temporarily in the hospital as well as delivered to MOH Licensed Company.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

182. Additional expert inputs. The project will provide expert inputs in several fields to ensure that the Songinokhairkhan District Hospital is operated in a safe and sustainable way. In addition, it is proposed to perform an audit of the completed facilities as part of hospital accreditation processes to verify that all waste management systems have been installed properly and are being operated properly.

7.5. Unanticipated Impacts During Construction and Operation

183. If any unanticipated impacts become apparent during project implementation, the borrower will (i) inform and seek ADB’s advice; (ii) assess the significance of such unanticipated impacts; (iii) evaluate the options available to address them; and (iv) prepare or update the IEE including EMP. The updated IEE will be disclosed on ADB’s project website.

8. INFORMATION DISCLOSURE, CONSULTATION, AND PARTICIPATION

8.1. Consultation and Participation During Project Preparation

184. During project design and preparation of the original IEE and this updated IEE, different public and stakeholder involvement processes were used by the PPTA team to gather stakeholder input on sector and needs assessment, project design and configuration. A series of consultation techniques were applied to engage stakeholders in the assessment and decision-making process and seek comments and concerns of affected people. The consultation and participation process allowed for a high degree of public and stakeholder input into the project design, including meetings with key governmental officials, experts, hospital managers and staff, environment authorities and affected people.

185. The consultation and participation process was adjusted to the specificity of the three project components, the anticipated risks and impacts, and the potentially affected groups. The MON: Fourth Health Sector Development Project- Second Additional Financing involves one major infrastructure component: the new Songinohairkhan district hospital under Component 1.

186. Public and agency consultation meetings were held in July 2012 in Ulaanbaatar and for the new SDH. Participants included a representative cross section of stakeholders including government officers, NGOs, academics and residents. This comprehensive consultation indicated that the majority of the affected people had a positive attitude toward the project and believed it would benefit them in the long term through increased safety, and an improved local environment. A GRM has been established in July 2011 to address public complaints related to project activities during project implementation and operation. Consultation and participation will continue throughout project implementation and any environmental complaints or disputes will be handled in accordance with the GRM.

8.2. Public Consultation for the new Songinohairkhan Hospital Component

187. Public consultation near the proposed new Songinokhairkhan district hospital project was carried out between 19th khoroo citizens on 19 June 2012. This public consultation was through interviews and filling environmental questionnaires by members of the community living around the hospital area.

188. The consultation covered 14 participants of age 22 to 63 including three male participants and 11 female participants. The consultation included the chairman of the hospital, the deputy director of the hospital, the chairman of quality department, 1 physician, 1 nurse, inpatients, private businessmen and women, herdsmen/ herdswomen and translators and also unemployed persons and pensioners (see Table 12).

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Table 11: Description of Participants in Hospital Public Involvement Program

№ Surname, name Age Sex Address Working status 1 Badrakh 52 male Bayangol district 6th khoroo Director of hospital Galsantseden 2 О. Enhtuya 53 female - Doctor of insurance 3 B. Purevjav 43 female Bayangol district 13th khoroo Deputy for clinics 4 Gombojav Teen 50 male SKH District Quality labor chief 5 Chunag Davaasuren 46 female SKH District, 5th khoroo Nurse 6 М. Tserensodnom 54 female SKH District, 20th khoroo, HТ- Doctor 48-10 7 B. Munkhnasan 32 female SKH District, 9th khoroo Translator 8 Gelegpuntsag 22 female BG District, Zuun naran 10-65 No work Tsendee 9 Byambajav 49 female SKH District, 3th khoroo, BN- Nurses Tsendhuu 43-30 10 L. Urantogos 45 female SKH District, 23th khoroo No work 11 Мagsar Оtgon 63 female Argalant II bagh of Tuv aimag Herders 12 S. Enkhjargal 48 female SKH District, 23th khoroo, 13- Individual 2 businessman 13 Kh. Demberel 40 male SKH District, 19th khoroo, 2- Individual 60-56 businessman 14 G. Batmunkh 32 male SKH District, 22th khoroo, 83- Individual 4 businessman

Pictures 3, 4: Local citizens giving interview at Songinohairkhan Hospital

189. Regarding the participants on the survey, 100% supported enhancement work of Songinohairkhan Hospital. Responses to the question “How do current hospital activities impact negatively to citizens, companies and environment?” are presented below.

190. In the survey, 62% of participants considered that the new hospital will have no negative impact on public health, environment, activity of citizens and legal entities. 23% of the participants considered that medical waste management will have minor impacts on air and soil, 7.5% of the participants considered that medical waste management will have medium impacts, and 7.5% anticipate significant impacts. Citizens who indicated that proposed hospital has high negative impact had no specific ideas on why they thought so.

191. Answers to the question “Please mark possible negative impacts during new hospital construction works” are presented in Figure 18.

Figure 18: Public Consultation Results and Songinohairkhan Hospital 58

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Relative to Construction Impacts

No a lot

Noise Odour and smog Dust waste water

192. One participant considered that harmful waste has no negative impact on construction, other participants considered that waste, noise, dust, smell, smoke, sewage and ash might have negative impacts. Following additional notes have been made by participants, about hospital activities and their new enhancement work: • It should be nice and safe for children; • The motor-road needs to be widened and parking lots should be established; • It should be built with good quality; • The project should be implemented without interrupting the activities of the current hospital; • Because morbidity is increasing following the population growth, the former hospital should be working continuously, and the former hospital building shall be used for pediatric care; and • It should be constructed within a short period of time.

193. The project preliminary design and the EMP took the comments from affected persons into account in the following ways: • Greening area is provided and appropriate for nearby residents and children. • Detailed access roadway plan was developed for improved access. • Current hospital is retained until new hospital is completed. • Comments on retention of the existing hospital not possible to take into account in new plans due to limited land available for parking and greening.

194. For the construction period, 75% of participants indicated no negative impact, 10% indicated a small amount of dust, noise, waste will be generated, and 15% answered that these impacts can be mitigated. There were no indications that hospital enhancement work impact to environment would be “strong” or “very strong”.

8.3. Future Information Disclosure and Public Consultation Program

195. Consultation with potentially affected people and key stakeholders will be maintained

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

throughout project implementation to ensure that public concerns are understood and dealt with in a timely manner. A plan for future consultation during detailed design and construction was developed and is presented below. The form of future consultation will depend on the issues arising during project implementation. It will include questionnaires surveys, household visits and public consultation meetings. (i) During detailed design. The PIU, LIEC and Involuntary Resettlement Consultant will conduct public consultation with affected people to discuss and inform about the planned project activities. A resettlement plan will be prepared. (ii) During Construction. Informal interviews with affected people will be conducted according to the Environmental Monitoring Plan. The consultation will focus on complaints about impacts from construction activities, such as traffic disturbance, construction noise, dust, solid waste and wastewater, and community health and safety. In addition, there will be a public information campaign, as part of the project’s Public Awareness Raising activities. Clear public notice boards will be set at each construction site to inform the public about the purpose of the construction, the duration of disturbance, the responsible entities on-site (contractor, PIU, IA), and the project’s GRM. Contact information of relevant organizations and project individuals will be disclosed on the construction site information boards.

196. Responsibilities. The IA, through the PIU, will be responsible for organizing the public consultations. The contractors will be required to communicate and consult with the communities in the project’s area of influence during mobilization and regularly thereafter, especially those near their construction sites and will need to understand and fulfill the requirements of the GRM and Health and Safety requirements in terms of displaying signboards at construction sites.

197. Information Disclosure. Environmental information on the project was and will be disclosed as follows: i) The updated IEE is available for review in the EA and PIU’s office; ii) The updated IEE is disclosed on ADB’s project website (www.adb.org); iii) Annual reports on project’s compliance with the EMP are available at: www.adb.org.

9. GRIEVANCE REDRESS MECHANISM

9.1. Introduction

198. In accordance with SPS, the project carried out meaningful consultation with key stakeholders, including potentially affected people near the new SDH. As a result of this public participation and safeguard assessment during the project preparation, major issues of grievance during project implementation are not expected. However, public complaints during project implementation cannot be excluded.

199. During construction of the new SDH complaints related to access issues, construction noise, inappropriate construction waste disposal, and construction site hygiene and safety might emerge. The complainants might include hospital patients, staff and visitors, nearby residents /workers /students, and construction workers. During operation, the most likely complaints relate to public health and safety concerns of the new SDH.

9.2. Proposed GRM for MON: Fourth Health Sector Development Project – Second Additional Financing

200. In order to settle possible grievances effectively, a Grievance Redress Mechanism (GRM) was established for the Fourth Health Sector Development Project in July 2011 and will be retained for MON: Fourth Health Sector Development Project – Second Additional Financing. The

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

GRM will be accessible to SDH staff and patients, and members of the community. Confidentiality and privacy of complainants will be respected, if requested by the complainants.

201. The PIU has designated a GRM coordinator. The FHSDP has an ongoing GRM and this GRM will continue as currently formulated. The GRM will be disseminated through information boards at replacement SDH construction site during contractor mobilization, with reference to the GRM and with contact numbers of the GRM access points. A guideline for the GRM has been prepared by the GRM coordinator, and it will be disseminated with the contractors, IA, hospital and medical waste staff, and the district governor.

202. The PIU, through the GRM coordinator, monitors the GRM at the hospital site. Entry points for the complaints will be the hospital administration, the contractor, the khoroo administrative unit and the GRM coordinator. The GRM coordinator will meet with the hospital and khoroo administration as well with the contractor before the construction starts and define focal persons who will be responsible for receiving complaints from public from each entry points. The GRM coordinator will provide short training for focal points by introducing guidelines and explaining the GRM functioning including complaint register, eligibility criteria, forms and templates will be used.

203. The GRM coordinator will assist focal points to develop user friendly information boards and suggestion boxes to be placed in the construction side and hospital to inform public, construction workers and hospital staff about receiving complaints and mechanism to resolve.

204. Hospital administration and contractor will place information boards and suggestion boxes in the construction site and in the hospital building to informing about GRM and receiving complaints.

205. 4-Step Approach will be used to deal with complaints during the construction and operation of hospital. [A separate GRM is established for operation of the Central Laboratory building and coordinated by GASI (IA)]:

206. Step 1: Informal problem solving (within 1 week) - Focal points at construction site (hospital and contractor) will receive oral and written complains (Annex 7, Form 1: Grievance Intake Form) related with construction and operation of the hospital. Upon receipt of complaint, the coordinator will discuss with administration of hospital and contractor to resolve issues. Once the issue is resolved, the focal point will inform complainant on how they solved the issue and whether this satisfies the complainant. If the issue was not solved, then focal point will forward it to GRM coordinator immediately (within 3 working days) through the Form 1. Focal points will inform to GRM coordinator on quarterly basis on received complaints filled in Form 1 and how complaints were tackled.

207. Step 2: GRM Coordinator suggests solution (within 1 week) - GRM Coordinator will receive complaints directly from complainants or indirectly receive forwarded complaints from focal points. GRM Coordinator will consult with complainant, IA and contractor in order to record complaint, assess eligibility and severity of complaint, propose corrective action plan and facilitate negotiation in accordance with Annex 7, Form 2: Grievance Recording and Assessment Form. GRM Coordinator will inform back to complainant on corrective actions taken and results of it. If the agreement was not reached, then bring it to the multi- stakeholder meeting discussion. ADB is informed of the complaint.

208. Step 3: Multi-stakeholder meeting (within 2 weeks) - PIU will call a multi-stakeholder meeting and discuss possible solutions and make decision to resolve complaint. Participants in the meeting include the PIU, complainant, contractor, IA, District Inspection Agency representatives, consultants, and any other parties involved in the complaint. PIU/GRM Coordinator will be responsible for monitoring the implementation of corrective actions and informing the status back to stakeholders who participated in the multi-stakeholder meeting in written form. ADB is consulted on the complaint resolution. 61

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

209. Step 4: Implementation and Documentation (within 3 weeks) - GRM Coordinator will make sure that all complaints are registered, assessed, proposed corrective actions delivered to the IA, contractors on timely basis and responsible for documenting, monitoring and follow up of the results. GRM Coordinator will quarterly receive compiled complains filled in the Form 1 with results of corrective actions from hospital and contractor and will include the section on GRM implementation status in the annual report. Based on review of the GRM implementation, GRM Coordinator will suggest changes in the GRM Guidelines in consultation with IA, contractor and ADB.

210. The GRM has been operational since July 2011 and will continue during the entire construction phase and during the first year of operation. During the first year of operation, a mechanism will be established to hand over grievance redress responsibilities to the operators and IAs, in consultation with the PIU. Figure 19 shows the process.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Figure 19: Fourth Health Project GRM

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

10. ENVIRONMENTAL MANAGEMENT PLAN

211. An Environmental Management Plan (EMP) has been developed for MON: Fourth Health Sector Development Project – Second Additional Financing which defines all potential impacts of components and the mitigation and protection measures with the objective of avoiding or reducing these impacts to acceptable levels. The EMP also defines the institutional arrangements and mechanisms, the roles and responsibilities of different institutions, procedures and budgets for implementation of the EMP. The EMP seeks to ensure continuously improving environmental protection activities during preconstruction, construction, and operation in order to prevent, reduce, or mitigate adverse impacts and risks. The EMP draws on the findings of the consultations with affected persons, IEE, PPTA and ADB review mission discussions and agreements with the relevant government agencies.

212. The EMP defines: (i) its objectives; (ii) responsibilities and authorities for EMP implementation; (iii) summary of impacts and mitigation measures; (iv) environmental monitoring and inspection plan; (v) institutional strengthening and training plan; (vi) reporting requirements; (vii) public consultation plan; (viii) cost estimates; and (ix) mechanism for feedback and adjustment. The EMP will be reviewed and updated at the end of the detailed design in order to be consistent with the final detailed design. The updated EMP will be disclosed on the ADB project website and included in the Project Administration Manual (PAM).

213. The full EMP is presented in Annex 1.

11. CONCLUSIONS AND RECOMMENDATIONS

11.1. Project Benefits

214. The expected impact of the MON: Fourth Health Sector Development Project Second Additional Financing will be to improve the health status of the Mongolian population, including the poor. The outcome will be improved health sector efficiency, governance, and drug safety. The impact of the project will be improved quality of health services in Mongolia. The project will directly benefit over 250,000 mostly poor residents of the Songinohairkhan District of Ulaanbaatar by improving district hospital services. The project will also benefit the entire population of Mongolia by improving access to safer drugs, and in the long run, will improve allocative efficiency in the health sector by optimizing the use of hospital services and improve return on future investment in the hospital sector. Improving both the country’s health services and the health status of the population will lead to a reduction in household expenditures and time spent seeking medical care. The poor will benefit particularly from the project’s drug safety activities as they are currently more likely to purchase and consume substandard pharmaceuticals.

11.2. Anticipated Impacts and Risks

215. The major MON: Fourth Health Sector Development Project –Second Additional Financing infrastructure component with potential environmental impacts is the new SDH under Component 1 and this infrastructure project is the primary focus of this updated IEE.

216. The principal impacts identified during screening related to the new SDH will arise during construction. These are (i) increased traffic congestion near the project sites; (ii) increased noise and dust levels; (iii) the removal of some existing facilities and the associated waste disposal requirements; and (iv) occupational and community health and safety issues. These impacts are considered reversible and site specific and can be mitigated to acceptable levels through sound environmental management planning.

217. The SDH is located in Ulaanbaatar city. The project will not encroach on legally protected 64

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

sites. The new SDH construction is ongoing within the existing Hospital compound, which has very little vegetation or exposed ground which may form habitats for fauna. There is a limited number of bird species observable in the city, such as crows and sparrows, common to many urban environments. The project will not encroach on any physical or cultural resources. According to the latest site plan, eight hashaa need to be resettled for additional parking area and to build a second access road on the western side on the SDH site. The government will be responsible for the resettlement of the households in accordance with ADB’s policies and guidelines on involuntary resettlement (ADB Safeguard Policy Statement, 2009).

218. During operation, the main potential impacts relate to the proper management of medical and hazardous wastes from the new SDH. On medical wastes, the new SDH will be equipped with an integrated waste management system in detailed design in compliance with the 2011 MOH Orders 158 and 179 on health care facility waste management. In addition, the hospital is located very close to the Ulaanbaatar Central Medical Waste treatment facility at the Naran Enger Landfill, which is proposed for improvement under the ADB Fifth Health Sector Development Project. A transportation management plan will be prepared to address access issues to the new hospital. For the Central Laboratory, it has been equipped with a wastewater neutralization system and a storage system for hazardous chemicals produced in the laboratories.

219. Occupational health and safety issues will be mitigated though stringent on site management controls. Contractors will be required to engage an Environment, Health & Safety Officer (EHSO), ensuring that all reasonable steps are taken to protect any person on the site from health and safety risks. The construction sites will provide safe and healthy workplaces, and machinery and equipment will be kept safe and in good working order.

220. The EA has agreed on a comprehensive list of covenants and assurances, to ensure the effective implementation of the measures and mechanisms for mitigating the potential impacts and risks and for enhancing the environmental and social benefits of the project. The project assurances are presented in Annex 6 of this updated IEE.

11.3. Overall Conclusions

221. Overall, the project is expected to have no significant adverse impact if mitigation and monitoring plans are implemented, and the environmental management and institutional capacities of the PIU and the IA are built up and strengthened through the implementation of the institutional strengthening and training plans defined in the EMP. The MON: Fourth Health Sector Development Project - Second Additional Financing will contribute greatly to the improvement of health and economic development of Ulaanbaatar and population of Mongolia.

222. The findings of this updated IEE show that MON: Fourth Health Sector Development Project – Second Additional Financing project does not anticipate any significant adverse environmental impacts. Consultations indicated that the majority of the potentially affected people had a positive attitude towards the MON: Fourth Health Sector Development Project as a whole and believed it would be beneficial. Any adverse environmental impacts in the MON: Fourth Health Sector Development Project – Second Additional Financing associated with the project will be prevented, reduced to acceptable levels as set out in the updated EMP. In addition, robust environmental management systems will be introduced, and institutional strengthening and personnel training will be established to ensure environmental sustainability of the project.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

12. REFERENCES

ADB. 2002. Environmental Policy and Operations Manual 20

ADB. 2003. Environmental Assessment Guidelines. Manila.

ADB. 1997. Environmental Impact Assessment in Developing Countries ADB, 2009. Safeguard Policy Statement

ADB 2005. Strategy For Improving Healthcare Waste Management, ADB Mongolia Country Environmental Analysis, November 2005

ADB 2010. Draft Grant Agreement, RRP and PAM for Fourth Health Sector Development Project: Improving Sector Governance

ADB 2010. Design Qualification Assessment - Central Laboratory Building Project for the State Specialized Inspection Agency, Véronique Pomatto and Frans Stobbelaar

ADB 2010. Environmental Infrastructure Improvements For Mongolia Health Care Facilities, PPTA Knowledge Paper, Larry Quinn.

ADB 2010. ADB 4th Health Project, Strategic Recommendations for Environmental Improvement at Mongolia Health Care Facilities, PPTA Knowledge Paper, Larry Quinn

MOH and MET, 2009. Joint MOH and MET Ministerial Order 249/201 of 2002 for management of medical wastes, MOH Order Number 293 of 09 Sep 2009 of the Minister of Health

MET 2009. Final Report on the Feasibility Study of the Hazardous Waste Management Facility in Mongolia, By: KORNYEZETTECHNOLOGIA KFT. (Environmental Technologies Ltd.), For: Ministry of Nature Environment and Tourism, June 2009, Budapest Hungary

WHO, 2005. Health care waste characterization survey, 2005, MOH/WHO (Sh. Enkhtsetseg, G. Enkhjargal, L. Eggerth, and L. Diaz)

WHO, 2007. Report of assessment of Health care waste management, 2007 conducted by MOH with WHO support (G. Enkhjargal, OIC Environmental Health, MOH, B. Zolboo, Environmental Health inspector, State Specialized Inspection Agency, A. Enkhtuya, Epidemiology inspector, State Specialized Inspection Agency, B. Tsetsegmaa, Epidemiology inspector, Ulaanbaatar City Inspection Agency, Sh. Enkhtsetseg, WHO/MOG Programme Officer L. Diaz, WHO STC)

IEE for the Upgrading of Songinokhairkhan District Hospital, Approved MET 2010. EIA for the New Central Laboratory, approved by MET in October 2010.

EIA for the Replacement of Songinokhairkhan District Hospital, MET approval anticipated in August 2012.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

13. ANNEXES

Annex 1. Environmental Management Plan

I. Introduction

1. This Environmental Management Plan (EMP) is updated for MON: Fourth Health Sector Development Project – Second Additional Financing and defines all potential impacts of the project components and the mitigation and protection measures with the objective of avoiding or reducing these impacts to acceptable levels. The EMP also defines the institutional arrangements and mechanisms, the roles and responsibilities of different institutions, procedures and budgets for implementation of the EMP. The EMP seeks to ensure continuously improving environmental protection activities during preconstruction, construction, and operation in order to prevent, reduce, or mitigate adverse impacts and risks. The EMP draws on the findings of the consultations with affected persons, initial environmental examination (IEE), project preparation technical assistance (PPTA) and Asian Development Bank (ADB) review mission discussions and agreements with the relevant government agencies.

2. The EMP will be reviewed and updated at the end of the detailed design in order to be consistent with any design revisions if required. The updated EMP will be disclosed on the ADB project website and included in the project administration manual (PAM).

II. Institutional Responsibilities

3. Figure 20 describes the proposed organizational structure.

Figure 17: Project Implementation Organizational Structure

Advises (for project purposes) Oversees (for project purposes)

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

4. As Executing Agency (EA), the Ministry of Health will be responsible for the overall implementation and compliance with the EMP and Environmental Monitoring Plan. The EA has established a Project Implementation Unit (PIU), which has the overall responsibility delegated by the EA for supervising the implementation of mitigation measures, coordinating the Project level Grievance Redress Mechanism (GRM) and reporting to ADB. The EA will coordinate internal and external professional sectors including the two IAs to make their contribution to environmental management plan and monitoring arrangements.

5. Project Steering Committee (PSC). The role of the PSC of the Fourth Health Sector Development Project will be continued for the Fourth Health Sector Development Project with Additional Financing. It is chaired by the Vice Minister of Health and composed of senior officials from Ministry of Health (MOH), Ministry of Finance (MOF), Ministry of Social Welfare and Labor (MSWL), Ministry of Environment and Tourism (MET), the State Social Insurance General Office, the Ulaanbaatar City Mayor’s Office, the National Center for Communicable Diseases, the General Agency for Specialized Inspection (GASI), the Health Sciences University of Mongolia, Pharmaceutical Association, Hospital Association, Mongolian Consumer Association, and the Mongolian Association of Family Doctors. The Project Steering Committee will: (i) provide strategic direction and orientation; (ii) approve annual budgets and annual activity plans; (iii) review and advise on the implementation progress; and (iv) provide assistance to the working groups on project components.

6. Implementing Agencies (IA). The Ulaanbaatar City Mayor’s Office (UCMO) is the IA for the new Hospital component. It will implement the establishment of the replacement demonstration hospital in Songinohairkhan in coordination with district authorities (Output 3 of the design and monitoring framework). The General Agency for Specialized Inspection (GASI) is the IA for the Central Laboratory. It will be responsible for the implementation of the upgrading of the drug control laboratory (Output 9 of the design and monitoring framework).

7. The IAs will be responsible for the environmental management and implementation of the mitigation measures during project detail design and construction. They will ensure that the updated EMP is carried out, arrange the environmental monitoring reviews, and respond to any adverse impact beyond those foreseen in the domestic EIAs and this updated IEE. Oversight is also provided from MET as well as General Agency of Specialized Inspection (GASI) and District Inspection Agency (DIA). The IAs will also attend to requests from these agencies and ADB regarding the mitigation measures and monitoring program.

8. Construction contractors and the IAs will be responsible for implementing the mitigation measures during construction under the supervision of the PIU and UCMO and GASI/DIA. After project completion, environmental management responsibilities will be handed over to the operators of the project facilities, including the UCMO for the new Songinohairkan Hospital.

9. Contractors at the new Songinohairkhan district hospital will be required to appoint an Environment, Health and Safety Officer (EHSO) responsible for daily monitoring and supervision, and evaluation of the implementation of mitigation measures. These contractors will be required to develop an Environmental, Health and Safety Management Plan (EHSMP). To ensure that the contractors comply with the EMP provisions, the PIU will engage a Loan Implementation Environmental Consultant (LIEC), who will prepare and provide the following specification clauses for incorporation into the bidding procedures: (i) a list of environmental management requirements to be budgeted by the bidders in their proposals; (ii) environmental clauses for contractual terms and conditions; and (iii) major items in the updated IEE and EMP. In addition, the PIU will continue to prepare annual environment progress reports and submit them to ADB.

10. Overall environmental responsibilities are outlined in Table 13.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Table 12: Environmental Responsibilities by Project Phase Responsible Phase Environmental Responsibilities Agencies MET Review detailed EIAs following MON procedures Project Comply with MET instructions on detailed EIAs EA, PIU Preparation Conduct IEE in accordance with ADB SPS ADB Review and approve IEE, including EMP, Disclose on ADB website Incorporation of environmental mitigation measures in detailed designs, Design institutes Detailed and bidding documents. Design PIU, IA, LIEC Update EMP based on detailed design, if necessary ADB, MET Approve updated EMP, if necessary PIU, IA, Incorporate mitigation measures and the EMP clauses in tendering tendering documents, civil contracts and contractors’ construction management Tendering company, DI plans. LIEC, ADB Review tendering documents; confirm project’s readiness EA, IA Advise on implementation of mitigation measures Implementation of mitigation measures and conduct internal Contractors, monitoring/supervision. (Small equipment civil works contractors have EHSO assigned staff member with EHS responsibilities, not EHSO) Coordinate GRM; supervise EMP implementation; conduct regular site PIU inspections; prepare monthly EMP progress reports; conduct training; support LIEC in preparing annual environmental progress report Construction Licensed Conduct quarterly environmental monitoring, prepare monitoring report laboratory Advise on the mitigation measures; provide comprehensive technical support to PIU, EA and IA for environmental management; conduct LIEC training; conduct annual EMP compliance review; prepare annual environmental progress reports. Conduct review missions; review and approve annual environmental ADB progress reports, including disclosure GASI/DIA Conduct inspections relative to compliance with Mongolian regulations and standards Conduct EMP compliance review, instruct IAs on environmental PIU management requirements; prepare annual environmental progress report for first year of operation Operation IA Implementation of mitigation measures as defined in EMP GASI/DIA Conduct environmental monitoring following approved monitoring plan Review and approve environmental progress report, disclose on ADB ADB project website ADB = Asia Development Bank; DI = Design Institute(s); LIEC = Loan Implementation Environmental Consultant; PIU = Project Management Unit; EA = Executive Agency; IA = Implementing Agency; GASI = General Agency of Specialized Inspection; DIA = District Inspection Agency: ED = City/aimag Environmental Departments; MET= Ministry of Environment and Tourism; EIA = Environmental Impact Assessment; IEE = Initial Environmental Examination; EMP = Environmental Management Plan; EHSO = Environment, Health and Safety Officer

11. Loan Implementation Environmental Consultant (LIEC). Under the loan implementation consultancy services, one national LIEC will continue supporting the project with (i) project preparation, including EMP update; (ii) EMP training, (iii) yearly environmental progress and compliance monitoring (iv) annual environmental monitoring and progress reporting; (v) identifying environment-related implementation issues and necessary corrective actions to be reflected in an action plan; and (v) undertaking site visits as required.

12. GASI, MET. Various governmental functions in Mongolia are shared by ministerial organizations and district organizations, and Ulaanbaatar City is the district related to the MON: Fourth Health Sector Development Project. As such, the MET works closely with city and aimag Environmental Departments (ED). GASI at the ministerial level works closely with its district inspection agencies (DIA).

13. Licensed laboratory. A licensed laboratory will be engaged by the EA to conduct quarterly environmental monitoring during the construction of the new Songinohairkhan district hospital, and during the first year of operations, following the approved monitoring plan. The licensed institute will comply with Mongolian Quality Assurance/Control procedures and regulations for sampling and monitoring of environmental media and assess compliance with 69

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Mongolian environmental quality standards for ambient air and noise quality.

III. Summary of Potential Impacts and Mitigation Measures

14. Potential environmental issues and impacts during the pre-construction, construction and operation phases, as identified in the updated IEE as well as corresponding mitigation measures designed to minimize the impacts are summarized below. The mitigation measures will be incorporated into the tendering documents (where appropriate), construction contracts and operational management plans, and will be undertaken by contractors, the implementing agencies (IAs) under the supervision of the PIU.

15. The effectiveness of these measures will be evaluated based on the results of the environmental monitoring to determine whether they should be continued, or improvements should be made. Improvements need to be confirmed through stipulated environmental management procedures.

16. Many of the mitigation measures will be shouldered by construction contractors in the construction phase while the EA and IAs will ensure that the agreed mitigation measures in the EMP will be included in the construction contracts and will be monitored and implemented. The mitigation measure costs are embedded and secured as part of the design and construction costs of the Project. The PIU will ensure that adequate costs for mitigation measures and monitoring activities are allocated accordingly.

17. Table 14 provides a Summary of Potential Environmental Implications and mitigation measures to address the impacts for the new SDH during both construction and operation and during operation of the Central Laboratory:

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Table 13: Summary of Potential Impacts Impact Potential (H)-Hospital Mitigation measures Implementation Supervision Monitoring factor/ Impacts and/or (L)-Laboratory Agency Agency Indicators Project Issues stage A. Detailed Design 1.Revision of Updating Mitigation measures defined in this EMP will be reviewed, DI, LIEC, IAs PIU, ADB Updated IEE Detailed Design IEE/EMP H updated and incorporated into the detailed design to minimize adverse environmental impacts and ensure occupational and community health and safety. B. Construction 1. Soil Soil erosion, H Soil erosion management plan to be prepared by the Contractor IA, PIU, LIEC, Visual inspection, Excavation, spoil contractor. MET monitoring report disposal Soil damage, H Store chemicals/hazardous products and waste on Contractor, Executor of IA, MET, DIA, Visual inspection, contamination impermeable surfaces in secure, covered areas; the energy and water LIEC monitoring report supply network Remove all construction wastes from the site to approved connections waste disposal sites; Establish emergency preparedness and response plan (Spill Management Plan);

Provide spill cleanup measures and equipment at each construction site and training to staff;

Water collection basins and sediment traps will be installed in all areas where construction equipment is washed. 2. Water supply Access to clean H Connect construction sites and new facilities to UB’s IAs PIU Contracts renewed and electricity water and water supply and electricity grid, renew contracts electricity 3. Surface Wastewater from H Connect construction sites and new facilities to UB’s Contractors, IAs PIU, MET, LIEC Connection to sewer water construction site wastewater collection system, renew contracts

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

4. Solid waste Construction and H Confined storage of solid wastes away from sensitive Contractor, IAs PIU, LIEC, MET Visual inspection, domestic wastes receptors and regularly take to approved disposal facility; Monitoring report generated on construction sites Provide appropriate waste storage containers for workers’ and construction wastes;

Use approved contractor to remove all wastes from sites;

Removal of residual materials, wastes and contaminated soils that remain on the ground after construction; Prohibit burning of waste;

Carefully handle waste asbestos if it is found during any demolition activities, following the ACM handling and disposal plans. 5. Medical Maintaining H Set up and manage a temporary room in existing hospital Hospital administration PIU, LIEC, MET, Visual Inspection, Waste temporary medical convenient for MOH Licensed waste hauling and DIA Monitoring report waste storage treatment company can pick up waste for treatment, until system until new new hospital and new medical waste system complete. building complete 6. Noise Noise from H Ensure that construction equipment is in good working Contractors, IAs, PIU, LIEC, MET, Citizen complaints, construction order and appropriate noise reduction equipment is Hospital administration DIA Monitoring report activities installed. Laboratory noise Maintain perimeter fence throughout project. monitoring did not Avoid work during weekend; prohibit work in night time exceed standards between 2200 - 0600. during construction

Ensure noise levels around the construction sites do not exceed 60dB (daytime) and 40dB (nighttime) Conduct noise monitoring during the construction work per Mongolia standards and regulations. Community H Interviews with residents living adjacent to construction Contractor, IA PIU, LIEC Citizen complaints, complaints about sites will be conducted on a weekly basis to identify monitoring report noise community complaints about noise and seek suggestions from community members to reduce noise annoyance.

Community suggestions will be used to adjust work hours of noise-generating machinery. Noise in existing H Relocate rooms nearest to the construction site Hospital Administration PIU, LIEC Visual Inspection hospital

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

7. Air quality Air pollution H Vehicles delivering granular and/or fine materials to the Contractor PIU, LIEC, MET Citizen and worker mainly dust sites must be covered. Materials storage sites must complaints due to use of covered or sprayed with water. heavy vehicles Extra care will be paid during dry, strong windy days. Construct perimeter fence to reduce wind impact on site of new hospital.

Water will be sprayed on construction sites once a day in the dry days.

Conduct air monitoring during the construction work, per Mongolia standards and regulations 8. Health and Health and safety H Define safety measures at the construction site to protect Contractors PIU, Hospital Number of incidents safety of workers, the workers and the public, including provision of Administration, and complaints hospital patients appropriate personal protective equipment (PPE) for LIEC, MET, DIA and visitors, workers and arrangement of warning signs to alert the China Embassy and nearby residents public of potential safety risks in and around the GASI conducted construction sites. training at laboratory

Perimeter fence to include protection for pedestrians walking outside fence.

Install health and safety sign board. Health and safety H Secure approval from relevant authority for proposed PIU, Contractor PIU, Hospital Detailed Design of medical gas medical gas storage building; Administration, Drawings, GASI storage LEIC, GASI inspection Ensure that facility complies with relevant GoM’s design codes and standards, including but not limited to: Guidelines on Production, Transportation, and Storage of Healthcare Related Gases by Joint Order No: A/172/167 of Minister for Health, Minister for Social Welfare, and Minister for Infrastructure in 1998, “Requirements for Pressurized Gas Cylinders and Safety Regulations” Minister of Energy, 04 December, 2007, Order 93, and MNS 0640: 1989 Fire safety requirements. Health of H Conduct examination of workers by qualified physicians PIU PIU, DIA Accounting and construction once yearly upon Order No: A/243 of Health Minister to Contractors record of medical workers doing involve the workers in preliminary and annual medical examinations demolition work examination, make research of professional reasoned disease. 9. Ecology Trees and grass H Replant vegetation and plant trees around hospital, per Contractor, Hospital PIU, LIEC, MET Greening area, around hospital standards and design plan. administration satisfaction of hospital staff and patients Plant cover H Restore the soil and plant covers by filling in, leveling, Contractor MET, DIA, LIEC Revegetated area, destruction and soil cultivating, fertilizing and vegetating the damaged areas. satisfaction of damage laboratory staff. 73

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

C. Operation of Songinokhairkhan District Hospital 1. Solid waste Hospital waste H An integrated waste management concept will be Hospital administration PIU, MET, MOH Accreditation; Citizen management plan developed according to the MOH Orders 158, 179 and complaints, training 380 on medical waste handling and waste management. programs Provide training in waste management to staff.

Non-hazardous H Ensure clean waste collection point, regular pick up by Hospital administration MET General condition solid waste municipal solid waste collection services, disposal into around hospital Naran Enger Landfill. Manage domestic waste collection site according to the guidelines.

Ensure agreement with municipal waste collection services for regular collection and disposal. Hazardous medical H The waste will be collected regularly and treated by the Hospital administration, MOH, MET, LIEC Availability of storage waste disposal MOH-Licensed Medical Waste Company (at their nearby MOH-Licensed Medical bags and boxes, medical waste treatment facility at the Naran Enger Waste Co. Ltd. cleanness of storage landfill. Hospital management will amend the contract room. with MOH-Licensed Medical Waste Co. Ltd in accordance with the increase of the medical and health care waste. Monitor hygiene around the hazardous waste storage point. Assign and train a specialist responsible for waste management and environment control.

2. Health and Chemical spills, H Develop and implement an emergency plan to respond to Hospital administration MET, MOH, PIU Citizen and patient Safety unhygienic spills and accidental exposure to hazardous waste. complaints, environment, Regularly monitor environmental pollution and hygienic monitoring report Power cuts, illicit conditions in and around the new hospital, define wastewater corrective actions if necessary. discharge Ensure adequate neutralization of wastewater prior to discharge into municipal sewer system. Provide alternative power supply for emergency situations.

Ensure supply of potable drinking water. D. Operation of Central Laboratory 1. Domestic, Solid waste: 20kg L Ensure clean organic waste collection point, regular pick Central laboratory MET and DIA, Results and non-hazardous of solid domestic up by Enhancement & service company of Khan-Uul administration LIEC conclusions of the waste waste produced district, disposal into Naran Enger Landfill. laboratory analyses daily. Wastewater: 10.0- L Domestic wastewater will be discharged to the municipal Central laboratory MET and DIA, Results and 12.0 m3 domestic sewer and treated at the centralized wastewater administration LIEC conclusions of the waste water treatment system of UB city. laboratory analyses produced daily.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

2. Hazardous Neutralization of L Acid or alkali-containing chemical wastes released during Central laboratory MET and DIA, Results and and chemical acid or alkali- the analyses will be first neutralized in a septic tank administration LIEC conclusions of the solid and liquid containing (1.5m3) and then discharged to the centralized laboratory analyses waste chemical waste sewerage system. released during analyses. Regularly monitor ph levels of the tank effluent. Storage of L Hazardous liquid wastes (5-10 L per month of Class 5 Central laboratory MET and DIA, Verification of hazardous low-level hazardous chemicals) will be stored in the new administration LIEC adequacy based on chemical hazardous waste storage tanks constructed on the site of design review for ISO wastes the laboratory (10 years storage capacity). certification in August 2012. Monitor the operations of the hazardous waste chemical storage system regularly to ensure safe storage, adequate ventilation, restricted access. 3. Air quality Indoor air quality L Ensure proper storage and labeling of chemical Central laboratory MET and DIA, LIEC Results and substances, protect from evaporation. administration conclusions of the laboratory analyses Use chemical substances in strict accordance with the relevant safe operational instructions.

Regularly monitor air quality in the work place. Ensure compliance of the ventilation system with ISO/IEC 17025. Pollution of the L Regularly monitor ambient air quality around the Central laboratory MET and DIA, LIEC Results and ambient air laboratory. In case the air pollution within the external administration conclusions of the environment exceeds over the maximal permissible level monitoring /MPL/, relevant measures intended to enhance the air quality should be planned and implemented.

4. Health and Chemical spills, L Develop and implement an emergency plan to respond to Central laboratory MET and DIA, LIEC Citizen complaints, Safety unhygienic spills and accidental exposure to hazardous waste. administration, assigned monitoring report environment, Regularly monitor environmental pollution and hygienic storage system operator Power conditions in and around the laboratory, define cuts, illicit corrective actions if necessary. wastewater discharge Ensure adequate disposal of wastewater into municipal sewer system.

Provide alternative power supply for emergency situations.

Ensure supply of high quality water. Abbreviations: ADB = Asia Development Bank; DI = Design Institute(s); LIEC = Loan Implementation Environmental Consultants; PIU = Project Management Unit; EA = Executive Agency; IA = Implementing Agency; GASI = General Agency of Specialized Inspection; DIA = District Inspection Agency: ED = City/aimag Environmental Departments; MET = Ministry of Environment and Tourism; EIA = Environmental Impact Assessment; IEE = Initial Environmental Examination; EMP = Environmental Management Plan; EHSO = Environment, Health and Safety Officer.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

IV. Environmental Monitoring Plan

18. The monitoring program in the EMP will serve as the template for assessing the potential adverse impacts imposed on the surrounding environment by the relevant projects, identifying the ways and measures to be implemented for the purpose of reducing and eliminating these impacts, and providing the budget estimates of the required monitoring expenses.

19. All relevant project-specific impacts to the environmental components by the implementation of the relevant MON: Fourth Health Sector Development Project – Second Additional Financing components will be monitored. The parameters are shown for each of the environmental components, the frequency of monitoring, location of sampling and measurement points, form of reporting the results of the analyses, and the summary into the operational reports as described in the updated EMP. The plan also identifies the methods for identifying those parameters, the schedule for conducting relevant monitoring-studies, the location of the monitoring points, the standards and norms and normative to be followed in monitoring.

20. Environmental monitoring reports will be reflected in project progress reports comprised of the implementation of environmental laws, regulations and policies, mitigation measures taken, training and capability building. Results of environmental monitoring will be included in the environmental reports prepared for ADB by the PIU.

21. Project monitoring is the key link to check the implementation progress with regard to the achievement of environmental protection measures. The program considers the scope of monitoring and supervision, environmental media, monitoring parameters, time and frequency, implementing and supervising agencies. Environmental monitoring will follow the methodology provided in the national standard methods for monitoring pollutants. Other associated standards are national environmental quality standards and pollutant discharge/emission standards. The monitoring and inspection plan includes the following:

i) Periodic EMP Compliance Monitoring: Compliance to the project’s environmental safeguard requirements, as defined in the updated EMP and loan covenants, will be undertaken prior to construction (to confirm the project’s readiness) and reported annually during construction by the Loan Implementation Environmental Consultant (LIEC), with the support of the PIU; ii) Legal Compliance Inspections: Compliance to construction standards legislation will be undertaken by the GASI/DIA, as appropriate; iii) Daily Construction Inspections: The Environmental, Health and Safety Officers are responsible for the daily ongoing conformance of the projects with the updated EMP; and iv) Quarterly technical monitoring: A licensed laboratory institute will conduct quarterly noise and air quality monitoring of the new Songinohairkhan hospital during construction.

22. The EMP targets the two main component projects of the new SDH and the new Central Laboratory during construction and operation. Details of monitoring are found in Table 15 and Table 16.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Table 14: Environmental Monitoring Program for Songinohairkhan District Hospital Mitigation Parameters To be Location Measurement Frequency Responsible Supervising Standards measures Monitored Agency Construction To monitor physical Noise level In the edge of Selected Quarterly Licensed PIU MNS 5002:2000. phase parameter during the nearest flat laboratory laboratory DIA Noisiness. General construction work, building, in equipments * requirement on labor mitigate possible edge of safety, hygiene, risk construction noisiness norm. To monitor air Toxic gas, Dust area 20 m MNS 5885: 2008: pollution during Polluted PM10 radius (2 Permissible maximum construction work, substances sample) level of air polluting mitigate possible PM2.5 substance and general risk NO2 requirement. Soil erosion and Adequacy of soil erosion In hospital area Site review Daily EHSO DIA contamination prevention measures Monthly PIU Adequacy of soil Yearly LIEC contamination prevention techniques Evidence of excessive soil erosion or soil contamination

Solid and liquid Adequacy of solid and In hospital area Site review Daily EHSO DIA waste liquid waste mgmt Monthly PIU management Presence of dumps or Yearly LIEC waste fires Construction site Adherence to site In hospital area Site review Daily EHSO DIA health and safety EHSMP, performance of Monthly PIU EHSO, worker Yearly LIEC complaints Community Health Adherence to traffic plan In hospital area Site review Monthly PIU DIA and Safety Adequacy of signage Yearly LIEC Adequacy of noise measures Accidents involving public and workers Emergencies and responses Public complaints about noise, air pollution, etc

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Mitigation Parameters To be Supervising Standards Location Measurement Frequency Responsible measures Monitored Agency Induced traffic Adequacy of and In hospital area Site review Monthly PIU DIA disturbance adherence to temporary Yearly LIEC traffic control plan Satisfaction of affected people EMP Compliance Project adherence In hospital area Site review Yearly PIU, LIEC EA Operating Regularly monitor Room fungus New surgery Selected Once per Licensed GASI of the and indoor air quality Toxic gas, Тоос and obstetrics laboratory year** laboratory district maintenance specially in new Polluted CO2 rooms, patient equipment’s* In 2 years phase surgery and substances SO2 rooms (Total of obstetrics rooms NO2 10 representing rooms) Control soil Number of bacteria (in 1 Around hospital Once per Licensed GASI of the MNS 5850: 2008. pollution gr) waste point year** laboratory district Permissible maximum Colititre within 10 m In 2 years level of soil polluting Cl.perferringens titre radius, substance and soil (1 samples) quality. Control on the - - - During the The quality Administration internal medical whole manager of the of the Hospital and health care operation Hospital waste classification permanen tly Post construction Post construction In hospital area Site review Once GASI/DIA EA Site inspection environmental condition Vegetation Tree and grass plantings In hospital area Site review Quarterly for UB City IA and success one year Environmental Department (ED) Interview with Overall satisfaction with In hospital area Site review Twice in first UB City and GASI EA Affected People project outputs year of Concerns and operation complaints Notes: *- ………… **- Since the monitoring which will be completed in every stage of the project will be held annually, the Hospital shall organize the future monitoring at its expense. Monitoring before construction work will be held only once.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Table 15: Environmental Monitoring Program for Central Laboratory Mitigation measures Parameters To be Monitored Location Measurement Frequency Responsible Supervising Agency Operating Field and Not to allow noise and sound exceed Laboratory GASI and At the work Laboratory over the norms reflected in the relevant Noise level Once a year administration MET maintenance places equipments and standards DIA phase devices Monthly inside In the air at the Dust, the GASI To monitor and reduce the air pollution work places and CO2, H2S workplaces, MET during the laboratory operation within the and NO2, Quarterly for DIA surroundings ambient air

- chemical properties In the vicinity of GASI To identify soil pollution level and keep - agrochemical parameters the construction Twice a year MET a monitoring over it - water extract analysis site DIA

- sensitivity parameters Water from the Laboratory GASI Ensuring the drinking water’s quality - oxygen regime laboratory’s equipments and Once a quarter MET and hygiene requirements, and safety - mineral composition water supply devices DIA -organic pollution parameters lines Only persons responsible GASI Permanent monitoring over the storage permitted to enter the warehouse Laboratory Basement-floor Twice a month MET of hazardous wastes of hazardous wastes for administration DIA monitoring

Wastewater with problematic Septic tank Laboratory GASI constituents to the centralized рН, BOD, COD, oxidization rate, outside the Laboratory equipments, Every quarter MET sewerage system only after fat, petrol products, etc. laboratory administration devices and tools DIA neutralization and detoxification building

Per agreement, 0.4 tons of solid Khan-Uul district, GASI domestic wastes shall be Improved Landfill - Twice a month Laboratory MET transported to Naran Enger of UB administration DIA landfill Storage and removal of solid and liquid

domestic wastes Liquid domestic wastes shall be Laboratory GASI supplied to the city’s centralized pipelines - - MET sewerage system DIA

Periodic Damage or breakdown Pure-water Water supply and GASI assessments of Laboratory building’s external networks of pure and supply lines and Twice a year Sewerage MET pure water and wastewater pipelines sewers Authority DIA wastewater lines

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

23. Environmental monitoring and supervision cost estimates. Costs for environmental monitoring and supervision include salaries and consultancy fees for the PIU, the LIEC and the EHSO, as well as costs for the environmental monitoring performed by a licensed laboratory. The salary costs of the PIU and LIEC will be covered by the EA; the salaries of the EHSO will be covered by the Contractors and budgeted in their contracts. Air and noise monitoring costs will amount to approximately $2,000 over 3 years. These expenses will be covered by the IA and included in the overall project budget.

V. Institutional strengthening and training

24. The capacity of the PIU, Implementing Agencies and contractors’ staff responsible for EMP implementation and supervision will be strengthened. All parties involved in implementing and supervising the EMP must have an understanding of the goals, methods, and practices of project environmental management. The project will address the lack of capacities and expertise in environmental management through (i) institutional strengthening, and (ii) training.

25. Institutional strengthening. The capacities of the EA and PIU to coordinate environmental management will be appointing one staff to EMP coordination and supervision. The appointment of one national environmental consultant under the loan implementation consultancy will further strengthen the EA’s and PIU’s environmental management and supervision capacities and ensure compliance with ADB’s Safeguard Policy Statement (SPS). The outsourcing of periodic monitoring of air and noise to a licensed laboratory will ensure adherence to quality assurance (QA) and quality control (QC) standards. The obligation of contractors to appoint Environment, Health and Safety Officers (EHSO) and to establish Environmental, Health and Safety Management Plans (EHSMP) for the construction site will help ensuring community and occupational health and safety. The proposed institutional strengthening plan is presented in Table 17. It is believed that these institutional strengthening measures, combined with clearly assigned responsibilities and roles, will allow adequate environmental management.

Table 17: Proposed Institutional Strengthening Measures Target Agencies Institutional strengthening measures Timing Defining institutional arrangements for environmental management, monitoring, and supervision During project EA, IA, PIU Defining positions and responsibilities preparation Appointing and recruiting PIU Recruiting and contracting licensed laboratory for Prior to initiation of civil Licensed laboratory environmental monitoring before, during and after works construction Recruiting and contracting one national LIEC for Prior to initiation of civil LIEC environmental management, environmental training, works EMP compliance review, and reporting Hire Environment, Health and Safety Officers for each Prior to initiation of civil construction site. Contractors, EHSO works Develop Environmental, Health and Safety Management Plans (EHSMP)

26. Training. The EA, PIU, IA and contractors will continue receiving training on environmental management, environmental supervision, mitigation planning, emergency response, public consultation and Grievance Redress Mechanism, occupational and community health and safety, and other environmental management techniques. The training topics, methods, and estimated costs for MON: Fourth Health Sector Development Project – Second Additional Financing are described in Table 18. Training will mainly be facilitated by the LIEC with support of experts under the loan implementation consultant services.

27. There are a wide variety of other international and national consultants as described in the PAM and briefly summarized in the IEE who will contribute to the institutional strengthening and training programs.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

28. Training format will include workshops. In particular, due to the prevalence of construction projects in Ulaanbaatar, on-site training will be used extensively, giving staff firsthand experience on how to identify and correct adverse environmental impacts.

Table 18: Training Program

Training Topic Targeted Timing Duration, Agencies Costs

EMP Implementation: Roles and IA, PIU,MET, Prior to and 2 x 1 day, Responsibilities, Monitoring, Supervision Contractors, during project $2,000 and Reporting Procedures Grievance EHSO implementation Redress Mechanism: Roles and Responsibilities, Procedures, Occupational and Community Health and Safety, Emergency Preparedness and Response Pollution Control and Environmental IA, PIU, Prior to and 2x 1 day, Monitoring, Inspection and Reporting, Public EHSO, during project $2,000 Consultation Contractors implementation Contractor Engagement and Management, including EMP Enforcement

29. In addition, the project will provide significant international and national expert inputs who all will have specific technical and environmental training and institutional strengthening components in their work. Expert inputs and related training and institutional strengthening activities are described earlier in the updated IEE report. These activities are included in the overall project scope and budget, and not repeated here to avoid double-counting.

VI. Environmental Reporting

30. Quarterly environmental monitoring reports. The licensed laboratory will prepare concise reports presenting the results of the EMP monitoring of air and noise, with an assessment of compliance/non-compliance with Mongolian ambient environmental air and noise standards.

31. Annual environmental progress reports. To ensure proper and timely implementation of the EMP and adherence to the agreed environmental covenants, the PIU will submit to ADB annual environmental progress reports, based on the quarterly reports of the licensed laboratory. The LIEC will support the PIU in developing the annual reports. The report should confirm the project’s compliance with the EMP, local legislation such as EIA requirements, and identify any environment related implementation issues and necessary corrective actions and reflect these in a corrective action plan. The performance of the contractors will also be reported on with respect to environmental protection and impact mitigation. The operation and performance of the project GRM, environmental institutional strengthening and training will also be included in the quarterly environmental performance report. Table 19 summarizes the reporting requirements.

Table 19: Reporting Requirements

Report Frequency Purpose From To Contractor’s Monthly Satisfy EMP Contractor PIU Progress Report Project Progress Quarterly General project progress, including PIU ADB Reports summary of EMP implementation Environmental Monitoring of air and noise Quarterly Licensed PIU Monitoring Report laboratory Annual Environmental Adherence to Environmental PIU, LIEC ADB, EA Progress Report Annually Covenants and EMP

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

VII. Mechanisms for Feedback and Adjustment

32. Based on environmental monitoring and reporting systems in place, the PIU shall assess whether further mitigation measures will be required. The effectiveness of mitigation measures and monitoring plans will be evaluated by a feedback reporting system. The PIU will play a critical role in the feedback and adjustment mechanism. If the PIU identifies a substantial deviation from the EMP, or if any changes are made to the project scope that may cause significant adverse environmental impacts or increase the number of affected people, then the PIU shall immediately consult ADB to discuss EMP adjustment requirements.

VIII. Cost Estimates for Environmental Management

33. The total project cost for MON: Fourth Health Sector Development Project is approximately $61.31 million.

34. The environmental protection related cost is $195,200 of the total estimated project budget. The major environmental protection costs include institutional strengthening, environmental management training, protection and mitigation measures during construction and operation, and awareness raising. Excluded from the cost estimates are infrastructure costs related to environment and public health which are included in the project direct costs as well as many other project activities which aim at ensuring sustainable and safe operations and maintenance of equipment, including training, institutional strengthening (i.e. GASI), and supervision. These are included in overall project costs, and not in the EMP.

35. Before construction, the PIU and IA have developed detailed responsibilities and requirements for contractors and provided detailed cost estimates of mitigation measures and environmental monitoring in the construction contracts. The PIU also prepared detailed responsibilities and prepared a work schedule. Environmental considerations have been incorporated into the procurement to ensure environmentally responsive procurement. Cost estimates for mitigation measures, environmental monitoring, public consultations, and capacity building are summarized in Table 20. These cost estimates do not include the remuneration costs for international and national experts, since they are covered elsewhere in the project budget.

Table 16: Cost Estimates for the Environmental Management Plan Songinohairkhan Central Total Source of Hospital Laboratory (USD) Funds (USD) (USD)15 Environmental mitigation 47,000 10,200 57,200 Contractors - Erosion control - Spoil management - Dust control - Noise control - Solid waste control - Site safety - Work camp hygiene - Traffic management Environment, Health and Safety Officer 10,000 10,000 20,000 Contractors Disposal of small buildings and existing 15,000 0 15,000 Contractors hospital in landfill Site revegetation 15,000 2,000 17,000 Contractors Environment monitoring 1,000 1,000 2,000 EA Loan Implementation Environmental 16,000 16,000 32,000 EA Consultant Training 2,000 2,000 4,000 EA Public consultations, 2,000 2,000 4,000 EA GRM coordination

15 The construction of the Central Laboratory has already been completed in December 2012. 87

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Operational inspections 2,000 2,000 4,000 EA Environmental assessment and ISO 20,000 20,000 40,000 EA auditing firm Totals 130,000 65,200 195,200 Project Cost = $61.31 million Source: PPTA Team

36. During project implementation, the budget will be adjusted based on actual requirements. Contractors will bear the costs of all mitigation measures during construction, which will be included in the tender and contract documents. The EA will bear the costs related to mitigation measures during operation. Costs related to environmental supervision during construction and operation will be borne by the PIU and the operators, respectively. Costs for capacity building will be borne by the project as a whole.

37. The cost for revegetation of the new Songinohairkhan district hospital and the new Central Laboratory was developed and included in the mitigation cost table above. This may be more appropriate for the capital cost of the project as a recommendation of the IEE, but it is carried as a mitigation cost for now.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Annex 2. Comparison of WB EHS for HCFs and MON: Fourth Health Sector Development Project – Second Additional Financing Components Relevant IFC EHS for HCFs Application - District Hospital

The design and functional layout of an HCF should ensure the Will be applied in following: separation of clean / sterilized and dirty / contaminated detailed design phase materials and people flows; development and inclusion of adequate disinfection / sterilization procedures and facilities; adequate space for the storage of recyclable materials (e.g. cardboard and plastic) for pickup; selection of heating, ventilation, and air conditioning (HVAC) systems that provide isolation and protection from airborne infections; design of water systems to provide adequate supplies of potable water to reduce risks of exposure to Legionella and other waterborne pathogens; provision of hazardous material and waste storage and handling areas; treatment and exhaust systems for hazardous and infectious agents; and selection of easily cleaned building materials that do not support microbiological growth, are slip- resistant, nontoxic, and nonallergenic, and do not include volatile organic compound (VOC)-emitting paints and sealants. Health care facilities should establish, operate and maintain a health MOH HWMS color coded system care waste management system (HWMS) adequate for the scale in place since and type of activities and identified hazards. 2001 regulation and will be enforced. Facilities should consider practices and procedures to minimize Will be applied in detailed design waste generation. phase. At the point of generation, waste should be identified and MOH regulations prescribe these segregated. Non-hazardous waste, such as paper and cardboard, multi- colored waste segregation glass, aluminum and plastic, should be collected separately and processes and they will be recycled. Food waste should be segregated and composted. followed and monitored. Infectious and / or hazardous wastes should be identified and segregated according to its category using a color-coded system. If different types of waste are mixed accidentally, waste should be treated as hazardous. Proper On-site Handling, Collection, Transport and Storage of Improved on-site storage system Wastes. proposed. Standard waste hauled to Naran Enger landfill. Medical waste hauled by MOH-Licensed Medical Waste Company and treated in medical waste facility. Transport waste destined for off-site facilities according to the MOH-Licensed Medical Waste guidelines for transport of hazardous wastes / dangerous goods facility hauling and treating in the General EHS Guidelines. medical waste for all UB hospitals under MOH oversight. Waste segregation measures should be employed to minimize Will be applied in detailed design entry of solid waste into the wastewater stream. phase. Relevant IFC EHS for HCFs. Application - District Hospital. If wastewater is discharged to sanitary sewage treatment systems, Will be applied in detailed design the HCF should ensure that wastewater characteristics are in phase. compliance with all applicable permits, and that the municipal facility is capable of handling the type of effluent discharged, as discussed in the General EHS Guidelines. Establish Universal / Standard Precautions to treat all blood and Will be applied in detailed design other potentially infectious materials with appropriate phase. precautions, Establish Universal / Standard Precautions to handle needles and Will be applied in detailed design sharps. phase. Implement immunization for staff members, as necessary (e.g. Will be applied in detailed design vaccination for hepatitis B virus, tetanus immunization). phase. Provide adequate supplies of PPE for personnel involved in waste Will be applied in detailed design management including: overalls / industrial aprons, leg protectors, phase. boots, heavy duty gloves, helmets, visors / face masks and eye protection (especially for cleaning of hazardous spills), and respirators (for spills or waste).

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Provide washing facilities for personal hygiene, particularly at Will be applied in detailed design waste storage locations. phase Provision to manage risk of toxic exposure to nitrous oxide; the Will be applied in detailed design halogenated agents halothane (fluothane), enflurane (ethrane), phase isoflurane (forane); and other substances typically used as inhalation anesthetics. Performance Indicators and Industry Benchmarks. No direct discharge of wastewater or incinerator air emissions. UB and MOH centralized systems. Environmental monitoring programs for this sector should be See IEE EMP implemented to address all activities that have been identified to have potentially significant impacts on the environment, during normal operations and upset conditions. Environmental monitoring activities should be based on direct or indirect indicators of emissions, effluents, and resource use applicable to the particular project. Monitoring frequency should be sufficient to provide representative data for the parameter being monitored. Monitoring should be conducted by trained individuals following monitoring and record-keeping procedures and using properly calibrated and maintained equipment.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Annex 3. Management Principles for Handling and Removal of Asbestos

If a likelihood of disturbing hazardous materials such as asbestos, lead paint and PCBs in electrical fixtures becomes apparent during construction, a hazardous waste management plan shall be developed. This management plan will especially be cognizant of the environmental risks associated with asbestos and follow these management principles.

Asbestos is the name applied to a group of six naturally occurring silicate mineral chains, of which the long fiver chrysotile is the most common. The material was appreciated because of its properties. Asbestos fibers are virtually indestructible, resistant to chemicals and heat, and they are very stable in the environment. They do not evaporate into air or dissolve in water, and they are not broken down over time. However, because it is so hard to destroy asbestos fibers, the body cannot break them down or remove them once they are lodged in lung or body tissues. They remain in place where they can cause disease. Particular attention is therefore required during works which will potentially disturb asbestos containing materials (ACM).

Based on International Labor Organization recommendations, the following minimal requirements will be adhered to in the management of asbestos during project works.

i. conduct careful inspection and documentation of the premises and testing of materials to assess the presence of asbestos containing materials (ACM).

ii. for small quantities of ACM in a particular building, and if the level of friable ACM is very low and unlikely to increase during demolition, the buildings may be removed without prior removal of asbestos. Workers may be provided with a suitable face mask and instructed to wash body, clothes and shoes after work before going home.

iii. for larger quantities of ACMs, or if the level of friable ACM is significant or may become significant during demolition, special arrangements need to be made for the removal of ACM before the demolition of the building.

➢ Where available, a national or regional company will be contracted which is specialized or at least has substantial expert experience with removing asbestos.

➢ The firm will follow standard's general requirements covering subjects such as notification and reporting and monitoring.

➢ The workers will be trained, provided with appropriate PPE, work in shifts to ensure proper use of PPE, wash after work, and are properly supervised. Laundry will be done on site to minimize exposure of children.

➢ The authorities will ensure that the buildings surrounding the demolition site are vacated during removal of asbestos and following clean-up. If friable materials are expected, the building will be covered in a protective tent of plastic.

➢ The firm will in any case use wet methods or wetting agents except where this is infeasible.

➢ The asbestos-containing waste produced from the demolition operation must be kept wet at all times until it has been loaded for transport away from the demolition site.

➢ Asbestos waste must be placed in sealed, labeled, impermeable bags or other closed, labeled, impermeable containers. Trucks with water-tight, dust- tight cargo haulers will take the containers to a proper storage place.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Annex 4. IEE - Project Design and Monitoring Framework Versus Positive/Negative Impacts (All negative impacts beyond demonstration hospital and drug control laboratory are small and not requiring mitigation)

Component 1: Strengthened Hospital Services in Ulaanbaatar Design Activities Positive Potential Summary Impacts Negative Impacts Output 1 1.1 Establish High Level Strategic 1.1 None 1.1 None Hospital development Planning Committee (2011) 1.2 Include environmental best 1.2 None policy and strategic 1.2 Review current situation and best practices for managing hospital 1.3 None plan for Ulaanbaatar practice and develop hospital policy infrastructure, 1.4 None (2012) 1.3 Strategy published in 2012 1.5 None 1.3 Develop strategic and financial 1.4 Including environmental investment plans (2011–2012) awareness 1.4 Wide communication on vision, 1.5 Improved strategy plans and implementation (2011– 2016) 1.5 Monitor and report on implementation of the strategic plan (2012–2016) Output 2 2.1 Review facility and equipment audit 2.1 Ensure capital planning 2.1 Secondary impacts A hospital capital system and capital planning system system includes improved of potential resource planning system is (2011) environmental infrastructure. depletion, induced established and 2.2 Support audit of facilities and 2.2 Include environmental growth and land use operational equipment (2012) infrastructure audit changes due to planning 2.3 Develop capital planning system 2.3 Same as 2.1 of new and expanded (2013) 2.4 Same as 2.1 facilities. 2.4 Implement hospital capital planning 2.2 Same as 2.1 system (2013) 2.3 Same as 2.1 2.4 Same as 2.1 Output 3 3.1 Review and design 3.1 Covered in Detail in the 3.1 Covered in Detail in A demonstration multifunctional hospital (2011–2014) IEE the IEE multi-functional 3.2 Monitor civil works (2014–2015) 3.2 Covered in Detail in the 3.2 Covered in Detail in general hospital 3.3 Develop new procedures, IEE the IEE established in systems, and organizational 3.3 Covered in Detail in the 3.3 Covered in Detail in Songinohairkhan arrangements (2012–2014) IEE the IEE district 3.4 Train staff (2013–2015) 3.4 Include environmental 3.4 Positive 3.5. Commission multifunctional management 3.5 Covered in Detail in hospital (2014–2015) 3.5 Covered in Detail in the the IEE 3.6 Arrange communication and IEE 3.6 Covered in Detail in public participation in implementation 3.6 Covered in Detail in the the IEE (2011–2016) IEE 3.7 Covered in Detail in 3.7 Support implementation, monitor, 3.7 Covered in Detail in the the IEE and evaluate (2015–2016) IEE Output 4 4.1 Review licensing legislation and 4.1 Include medically-related 4.1 None Increased hospital regulations (2011) environmental infrastructure 4.2 None governance 4.2 Review hospital governance systems in regulations 4.3 Need for additional arrangements and improve hospital 4.2 Include environmental medical waste treatment governance (2012) management facilities 4.3 Develop monitoring and evaluation 4.3 Once managed properly, procedures (2012–2013) may eliminate improper disposal

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Component 2: Strengthened Human Resource Development Design Summary Activities Positive Impacts Potential Negative Impacts Output 5 5.1 Review organizational framework for medical 5.1 None 5.1 None Strengthened post education and clarify roles (2011–2012) graduate 5.2 Develop and update post graduate curricula 5.2 None 5.2 None specialist structure to international standards (2012) and residency 5.3 Support professional associations and 5.3 None 5.3 None programs developed business plans (2012–2016) Output 6 6.1 Assess management training provided by 6.1 Include environmental 6.1 None Hospitals other parties management training in 6.2 None management (THSDP, WHO) (2011) assessment. 6.3 None module integrated 6.2 Identify local institution to provide 6.2 None in a local training hospital management t raining 6.2 Include environmental institution 6.3 Train managers to support multi-functional management hospitals (2012–2013)

Component 3: Strengthened Drug Safety Regime

Design Activities Positive Impacts Potential Negative Summary Impacts Output 7 7.1 Investments in support 7.1 Assist in removal of illegal 7.1 None. Establish a Drug systems and quality management drugs from the market. Regulatory for DRA (2011–2014). Authority 7.2 Identify and implement 7.2 Institutional development plan 7.2 None. organizational and regulatory of the Drug Regulatory Agency changes required (2011– approved and implemented. 2013).

7.3 Provide capacity building on 7.3 Same as 7.1. and 7.2. 7.3 Potential to dump illegal regulatory functions (2011– drugs on land or in sewer 2013). systems. Output 8 8.1 Review and develop 8.1 More than 80% of regulatory 8.1 None Strengthened regulations, procedures and job functions (registration, inspection, drug regulatory descriptions (2011–2014). laboratory, GMP) score positive. functions 8.2 Develop professional and 8.2 Baseline review 2011, 8.2 Potential abandonment support system of regulatory verification 2015. of illegal drug manufacturing functions (WHO list) (2011–2015). operations requiring environmental remediation. 8.3 Improve external 8.3 ….. communication and transparency 8.3 Same as 8.2 (2011–2015). Output 9 9.1 Procure equipment, 9.1 Covered in Detail in the 9.1 Covered in detail in the Upgraded drug Information Management System IEE. IEE. control and IT Infrastructure (2011– laboratory, 2015). including accreditation 9.2 Develop quality management 9.2 Covered in Detail in the 9.2 Covered in detail in the system system, validation, and ISO- IEE. IEE. 17025 certification (2011–2015).

9.3 Provide capacity development 9.3 Covered in Detail in the 9.3 Covered in detail in the on laboratory management, quality IEE. IEE. assurance and use of new equipment (2011–2014).

9.4 Develop laboratory 9.4 Laboratory accreditation 9.4 Once labs approved accreditation system (2013–2014) system approved by MOH by and operating under 2014 improved environmental management, could increase quantity of waste materials that requires proper handling and disposal. 93

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Output 10 10.1 Review and upgrade GMP 10.1 GMP guidelines and 10.1 May induce Implementation standards, regulations, and inspectorate under GASI upgraded production of waste of Good legal base (2011–2013). to PIC/S standard by 2012. materials in facilities Manufacturing upgraded to good Practices environmental practices. 10.2 Upgrade GMP 10.2 At least 5 local drug inspectorate, guide inspections manufacturers certified by 10.2 Same as 10.1. and company certifications upgraded GMP standard by 2015. (2011–2016)

10.3 Develop manufacturer 10.3 Include environmental best 10.3 Same as 10.1 capabilities to upgrade facilities practices in the facility upgrades and train personnel (2011–2016) and training Output 11 11.1 Review information collection, 11.1 90% of drug committees 11.1 None. Strengthen post analysis, reporting, and reporting quarterly by 2013 from marketing dissemination for market 50% in 2009 (reporting irregularly). surveillance and surveillance and ADR monitoring adverse drug (2011–2012). reaction monitoring 11.2 Develop market 11.2 Annual feedback and 11.2 None. surveillance and ADR training corrective action reports by 2014 course and seminars (2013– 1016). Output 12 12.1 Develop drug safety 12.1 Annual overview of drug 12.1 Potential Strengthen drug monitoring and communication safety indicators and abandonment of illegal drug safety plans (2012– 2014). achievements by 2013. manufacturing operations governance requiring environmental function at MOH remediation. 12.2 Improve capabilities and 12.2 MOH public information on support systems to perform drug safety including Rapid Alert 12.2 Same as 12.1 governance function (2011– System improved by 2014 (data 2014). on persons affected by unsafe drugs are gender disaggregated) 12.3 External communication and 12.3 Same as 12.1 reporting improvements (2011– 12.3 2016)

General Activities Design Summary Activities Positive Impacts Potential Negative Impacts 13.1. Implement and report on the 13.1 None. 13.1 None. Gender Action Plan (2011-2016).

13.2. Implement community 13.2 Included as part of IEE. 13.2 None. mobilization and Consultation and participation plan (2011-2016).

13.3. Implement and report on the 13.3 Integral part of IEE. 13.3 None. Environmental Management Plan (2011-2016).

13.4 Establish the project website 13.4 Additional Public 13.4 None. accessible to the public (2011). Consultation. ADR = adverse drug reaction; DRA = Drug Regulatory Agency; GIA = government implementing agency; DOH = Department of Health; GASI = General Agency for Specialized Inspection; GMP= Good Manufacturing Practice; ISO = International Organization for Standardization; THSDP = Third Health Sector Development Project; MOH = Ministry of Health; MHSU = Mongolian Health Sciences University; MDG = Millennium Development Goals; PIC/S = Pharmaceutical Inspection Cooperation/Scheme; PIU = project implementation unit; UB = Ulaanbaatar; WHO = World Health Organization.

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Annex 5. GRM related Forms Form 1: Grievance Intake Form The 4th Health Sector Development Project welcomes suggestions, comments and queries regarding the project implementation and its stakeholders. We encourage persons with grievances to provide their name and contact information to enable us to get in touch with you for clarification and feedback.

Should you choose to include your personal details but want that information to remain confidential, please inform us by writing/typing "(CONFIDENTIAL)" above your name. Thank you.

Contact Information Name Gender □ Male □ Female Home Address Age Phone No. City/Province Email Complaint/Suggestion/Comment/Question Please provide the details (who, what, where and how) of your grievance below:

How do you want us to reach you for feedback or update on your comment/grievance?

Portion to be filled in by the GRM focal point: Date received:

Received through: In person mail email suggestion box phone others Name of staff who receive comment/ complaint Position of focal point:

Type of Grievance:

Remarks

Problem solved Yes (provide details in ‘Remarks’ section above) locally? No, Grievance forwarded to GRM coordinator on (date) Signature of focal point

Portion to be filled in by the GRM Coordinator:

Grievance forwarded to GRM coordinator on (date) Grievance Registration Number:

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

Form 2: Grievance Recording and Assessment Form

A. Complainant Information (Person Reporting): 1. Name: 2. Address: 3. ID-No: 4. Gender: Female Male 5. Telephone: 6. Email:

7. Type of Complainant:  Affected person(s)  Intermediary (on behalf of the AP)  Civil organization  Service organization (e.g. local government institution)  Others (specify)

8. If Reporting Person is not Affected Person (AP), specify who are APs:

B. Complaint Details 9. Mode of receiving grievance:  Letter (Ref. No. )  Phone Call (Date: )  Fax (Ref. No. )  Email (Ref. No. )  Verbal complaint (Date: )  Suggestion Box (Date: )  Others (Specify: ) 10. Details of person that received complaints:  Official GRM entry point GRM coordinator Other ( ) Name: Position: Date: 11. Location of the problem/issue specified in the complaint (District, address):

C. Preliminary assessment of problem/issue 12. Type of problem:  Related to Central Laboratory Construction  Related District Hospital Rehabilitation  Related to other component (specify): 13. Description of the problem:

14. Description of factors/institutions/persons likely to cause the problem:

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

15. Seriousness of the problem: - (Potential) damage to environment  high  medium  low - Risk to community health and safety  high  medium  low - Risk to occupational health and safety  high  medium  low - Threat to overall project success  high  medium  low - Public profile of the issue  high  medium  low -> Overall seriousness of problem  high  medium  low

16. Actions taken by Complainant before filing formal complaint:  No action  Contact person/agency perceived as causing the problem  Other action (specify):

17. Actions taken by person/agency most likely responsible for causing the problem:  No action  Action (specify):

D. Eligibility Assessment 18. The complainant is identifiable and has provided a name  Yes No and contact details

19. The complainant or the AP he represents is/are affected by  Yes No the project

20. The complaint has a direct relationship to the project  Yes No

21. The complaint relates to environmental issues, or  Yes No occupational and community health and safety issues 22. Based on the above, the complaint is eligible  Yes No

E. Overall Assessment and Suggested Actions by GRM Coordinator

F. Actions taken Action Name of Action Officer Date

Fourth Health Sector Development Project – Additional Financing (RRP 41243)

G. Final Resolution

H. Supporting Documents and Attachments   

I. Name and Person Completing the Form

Signature: Name: Function: Date: ______

Fourth Health Sector Development Project – Additional Financing (RRP 41243)