Armenia Health Systems Modernization Project

Home , Getar, Goris, Meghri, Police of Armenia, Shirak Plain, Yerevan City Council

ARMENIA HEALTH SYSTEMS MODERNIZATION PROJECT

Public Disclosure Authorized

Public Disclosure Authorized THE NEW MEGHRI REGIONAL MEDICAL CENTER

FULL SCALE ENVIRONMENTAL IMPACT ASSESSMENT REPORT

AND

ENVIRONMENTAL MANAGEMENT PLAN

Public Disclosure Authorized

Yerevan, August 2012

Table of Contents

EXECUTIVE SUMMARY ...... 1

1. Introduction ...... 4 2. Methodology...... 5 3. Legal and Administrative Framework ...... 5 3.1 National Legislation ...... 5 3.2 Permits and agreements required prior to commencement of construction works and during operation of a medical center ...... 10 3.3 International Agreements ...... 11 3.4 The World Bank Safeguard Policies ...... 12 3.5 Administrative Framework ...... 13 4. Legal and Administrative Framework ...... 14 4.1. Location description ...... 14 4.2. Climate ...... 16 4.3. Water resources ...... 17 4.4. Air Quality ...... 18 4.5. Biodiversity ...... 19 4.6. Specially protected nature areas ...... 20 5. Social and Economic Conditions ...... 20 6. Project Description ...... 22 7. Project Aternatives...... 26 7.1. “No Action” alternative ...... 26 7.2. The initial option ...... 27 7.3. The selected option ...... 27 8. Environmental Impacts of the Project ...... 28 8.1 Consturction Phase...... 28 8.2. Operation Phase ...... 33 9. Mitigation of the Expected Risks ...... 36 9.1 Construction Phase ...... 36 9.2 Operation Phase ...... 37 10. Affected Parties and Public Consultations ...... 38 11. Environmental Management Plan ...... 38 11.1 Responsibilities and Institutional Arrangements ...... 38 11.2 Responsibilities of Construction Contractor ...... 38 11.3 Monitoring of EMP implementation ...... 38

Annex I. References ...... 39 Annex 2. Environmental Management Matrix ...... 41 Annex 3 Calculation of Emissions, Water Use and Water Discharge ...... 53 Annex 4. Calculation of Economic Damage ...... 58 Annex 5. Waste Generation...... 60 Annex 6 Public Consultation ...... 61 Annex 7. Certificate of Absence of the Known Historical and Archeological Monuments from the Project Site...... 64 Annex 8. Land Certificate Issued for the Allocated Site ...... 65

LIST OF ABBREVIATIONS

MAC - Maximum Admissible Concemtration MPE - Maximum Permissible Emission MPE - Maximum Permissible Discharge SNCO - State Non Commercial Organization WB - World Bank RA - Republic of Armenia MoH - Ministry of Healthcare MNP - Ministry of Nature Protection UN - United Nations UNDP - United Nations Development Program EIA - Environmental Impact Assessment PM - Particulate Matter VOC - Volatile Organic Compaund DRR - Daily Regulated Reservoir ENA – Elektric Networks of Armenia CJSC - Closed Joint Stock Company GEF – Global Environment Facility BOD – Biological Oxygen Demand HPIA – Health Project Implementation Agency

EXECUTIVE SUMMARY

Health System Modernization Project-2 (HSMP-2) is the second phase of two-phase Adaptable Lending Program (APL) provided by the World Bank in support to the Government’s health sector reform program. The development objective of the HSMP-2 is to strengthen the Ministry of Health’s (MoH's) capacity for more effective system governance, scaling up family medicine- based primary health care and upgrading selected healthcare service delivery networks in marzes to provide more accessible, quality and sustainable health care services to the population. HSMP-2 continues supporting the Government of Armenia (GOA) to: (i) complete the family medicine based Primary Health Care (PHC) reform that was launched in 1996 so to ensure that every Armenian citizen and legal resident will have access to a qualified and well motivated family doctor and nurse of his/her choice; (ii) consolidate the hospital sector to minimize waste of scarce resources and improve quality of care; and (iii) strengthen GoA’s competencies for effective stewardship in policy making, regulation, oversight and public accountability ensure effective and targeted use of public resources in accordance with the health and healthcare needs of the population, especially the poor.

HSMP-2 started in 2007, before the completion of the first phase of the Program, in view of the progress made toward meeting the trigger conditions of the program. HSMP-2 was scheduled for the period of five years ending December 2012. In July 2011, though, the Additional Financing was provided for the Project, which covers financing gaps of ongoing activities and scales them up. With the AF included, the HSMP-2 is expected to end in December, 2014.

The Government of Armenia adopted a revised optimization plan (amendment to Government decree N 1172 from 03.09.2010) which includes construction of a new building for Meghri Regional Medical Center to serve the entire population of the Meghri region and provide all kinds of hospital and polyclinic services. This would result in vacation of Agarak hospital, Meghri hospital, and several polyclinic buildings.

The Meghri region currently has hospital facilities at two locations – in Meghri and in Agarak cities. The conditions of all existing buildings are not satisfactory and significant investment is required in infrastructure of each of them to bring them in line with modern standards of hospital and polyclinic care and create acceptable conditions of delivery of medical services to the regional population.

Two options are considered: - merge the Meghri medical center and Agarak hospital in the existing premises, or - construct a new medical center

Taking into consideration all circumstances, it was decided to construct a new, up-to-date medical center in Meghri region with optimal localization and size, where all medical care services will be centralized.

The hospital building designed for 45 beds will be a two-storied structure having 51.0 meters x 51.0 meters of core size. The total area of the land plot allocated for the Medical Center makes 12069 square meters. The dimensions of an internal yard of the building will be 18.0 x 18.0 m. The land plot allocated for the construction is State owned. No formal or informal land use is registered on the plot at present. Power will be provided to the hospital building from the existing distribution network via an autonomous transformer to be constructed as part of the project. Emergency power supply will be arranged using a power generator running on the fossil fuel. Water will be provided from the existing water supply network and the wastewater will be received at the autonomous treatment plant due to lack of a municipal sewerage system. A boiler house operated on the natural gas will provide hot water and heating.

During operation of the Medical Center the medical waste, chemically active hazardous waste, household waste, and waste water will be generated. These wastes will be separated on site and disposed of according to categories. Due to tack of municipal waste water collection system, liquid waste from the Medical Center will be channeled to the autonomous treatment facility for filtering and biological deactivation.

Based on the nature and scope of physical activities required for the construction of a Meghri Regional Medical Center in the allocated site, as well as the general types of impacts expected from such kind of construction, it is classified and environmental Category B and requires Environmental Impact Assessment (EIA). The EIA work was based on the desktop review of literature, detailed study of the building design, and field work for verifying available data and examining present status of the physical and biological environment on site. The EIA was carried out in compliance with the law of the Republic of Armenia on the Expert Analysis of Environmental Impact and the World Bank OP/BP 4.01 - Environmental Assessment. The project does not trigger any other safeguard policy of the World Bank. Construction of the Medical Center will require obtaining of the conclusion of the expert analysis of the environmental impact from the Ministry of Nature Protection of the RA.

Land plot allocated for the construction of the Medical Center is located within urbanized area of Meghri municipality. Vegetative cover of the plot is scares and limited to grass and few shrubs. The plot is in no formal or informal use of any kind. Meghri-Yerevan-Agarak highway passes closes to three sides of the plot. Meghri River flows along its northern border, and Araks River passes on the East and the South. Residential and agricultural areas are in the vicinity of the allocated land plot. No forests, wetlands, designated protected areas, or other sensitive receptors are situated close to it.

The expected environmental and social risks associated with the construction of the Meghri Medical Center are moderate and can be effectively mitigated.

Impacts of the construction phase: - Air pollution from the operation of the construction vehicles and machinery; Land degradation and erosion as a result of damaging vegetative cover and disruption of topsoil; - River pollution with runoff from the construction site; - Damage to the landscapes and ecosystems from borrowing of construction materials; - Improper disposal of access material and construction waste; - Nuisance for local community due to noise, vibration and dust due to movement of the construction vehicles and machinery; - Nuisance for local agricultural land owners due to temporary storage of construction materials and construction waste. 2

Mitigation measures of the construction phase: Risks of the construction phase could be effectively mitigated by adherence to common good construction practice, implying: - Keeping construction vehicles and machinery in good technical condition; - Fueling, washing, and otherwise servicing vehicles and machinery at the service centers or in the designated locations of the construction site which can contain operational and accidental spillage of oils and lubricants and does not allow direct water discharge to the natural water bodies; - Moving vehicles and machinery along the existing or designated access roads to avoid excessive damage of natural vegetation; - Operating vehicles and machinery within working hours and shutting engines when idle; - Keeping subsoil and topsoil separately and using them for backfilling and reinstatement of the construction site; - Keeping construction materials and waste within the construction site and periodically disposing them into the formally designated locations; - To the extent possible, purchasing inert construction materials (sand, gravel, rock) from the already registered operating vendors. If mining for them is required, obtaining and observing license terms, and ensuring reinstatement of the used borrow sites.

Impacts of the operation phase: - Environmental pollution from the operational or accidental spillage of liquid fuel; - Failure in regular servicing of the waste water treatment unit resulting in the release of untreated water and leading to the pollution of the ground water and nearby rivers; - Accumulation of excessive amounts of waste on-site due to failure of its timely removal; - Open air burning or illegal dumping of waste resulting in the pollution of soil and water as well as in risks of spreading disease to local communities.

Mitigation measures of the operation phase: - Establish adequate regime of servicing and maintenance of the boiler house operation, check technical condition of the appliances and periodically monitor emissions. - Ensure smooth operation of the waste water treatment plan through regular servicing of the unit. Keep sludge in a properly insulated and roofed drying platform, excluding leakage of runoff. - Arange and maintaining effective drainage system for the collection and discharge of storm water to avoid waterlogging of the Medical Center area and the territory around it. - Collect household waste in regular plastic binds and regularly dispose of at the municipal landfill. Make and maintain proper arrangements for out-transportation of waste with scavenger trucks. - Collect medical waste separately in special containers and regularly hand it over for disposal to a specially licensed entity. - Accumulate chemically active liquids, especially solutions for the processing of X-ray films, separately from other liquid waste in special containers and hand it over for deactivation and disposal to a specially licensed entity. - Disallow burning of any type of waste in open air at or around the Medical Center site.

Institutional Arrangements for Managing Environmental Impacts Due application of the identified mitigation measures during construction of the Mecial Center is the responsibility of the project implementing entity - the RA Ministry of Health through the Project Implementation Unit under it. Once operational, the Medical Center will be managed by the Directorate carrying responsibility for the smooth operation of the facility. Environmental compliance of the Center’s operation will be enforced by the Syunik regional unit of the RA State Environmental Inspectorate. 3

1. Introduction

Health System Modernization Project-2 (HSMP-2) is the second phase of two-phase Adaptable Lending Program (APL) provided by the World Bank in support to the Government’s health sector reform program. The development objective of the HSMP-2 is to strengthen the Ministry of Health’s (MoH's) capacity for more effective system governance, scaling up family medicine- based primary health care and upgrading selected healthcare service delivery networks in marzes to provide more accessible, quality and sustainable health care services to the population. HSMP-2 continues supporting the Government of Armenia (GoA) to: (i) complete the family medicine based Primary Health Care (PHC) reform that was launched in 1996 so to ensure that every Armenian citizen and legal resident will have access to a qualified and well motivated family doctor and nurse of his/her choice; (ii) consolidate the hospital sector to minimize waste of scarce resources and improve quality of care; and (iii) strengthen GoA’s competencies for effective stewardship in policy making, regulation, oversight and public accountability ensure effective and targeted use of public resources in accordance with the health and healthcare needs of the population, especially the poor.

The decree of the Government of Armenia #1911-N of Nov 2, 2006 approved the master-plans of optimization of regional health care delivery systems developed in the scope of the first phase of the project. Modernization activities cover Hrazdan MC of Kotayk marz, Ijevan MC of Ijevan marz, Armavir MC of Armavir marz, Ararat MC of Ararat marz, Aparan MC of Aragatsotn marz, Goris MC of Syunik marz, Gavar MC of Gegharkunik marz, and the Gyumri new MC of Shirak marz. Currently the 8 hospitals are renovated/constructed, provided with modern medical equipment and furniture. The Government of Armenia adopted a revised optimization plan (amendment to Government decree N 1172 from 03.09.2010) which includes construction of a new building for Meghri Regional Medical Center to serve the entire population of the Meghri region and provide all kinds of hospital and polyclinic services. According to the project it is planned to be build a new hospital on the unused lands of Meghri city, which will have 45 hospital beds and be provisioned with modern medical equipment and furniture. The project also provides for technical assistance aimed at improvement of management systems and structures and development of new management functions, such as quality management and health care waste management.

The new building for Meghri Regional Medical Center will be equally accessible for the entire population of Meghri region and will host an institution available to provide all kinds of hospital and polyclinic services. The implementation of this plan would result in vacation of Agarak hospital, Meghri hospital and polyclinic buildings. The planned activities will not affect the physical accessibility of medical services provided to the population of Syunik, as while proposing amendments the geographic location of medical institutions and existence of bordering regions had been taken into account.

2. Methodology

The present EIA was carried out according to the Terms of Reference agreed upon with its main financier - World Bank - and covered the entire scope of the Project, including construction phase and operation of the Medical Center. The EIA process included desk work to review project documents and scientific literature, as well as field work aimed at verification of the available data, collection of missing information, and meetings with the Project stakeholders. The background information was compiled on the biophysical environment around the Project site, on the land tenure and land use of the allocated plot and its adjacent area, on the existence on the known or potentially present elements of historical and cultural heritage in the vicinity of the Project site, and the status of the allocated site was documented by creating of photo material.

Based on the background material, sensitive environmental receptors were identified and potential environmental and social impacts of the Project were defined for the construction and operation phases. Estimated costs were calculated for several discrete and most important mitigation measures for the inclusion into the bill of quantities for the upcoming civil works. A detailed Environmental Management Plan was developed listing specific activities carrying environmental and social risks and measures prescribed for their mitigation. Indicators for quantitative or qualitative measurement of the effectiveness of mitigation measures were selected and used for the development of an Environmental Monitoring Plan.

3. Legal and Administrative Framework 3.1 National Legislation

The 10th Article of the Constitution of the Republic of Armenia (adopted in 1995 and amended in 2005) states the State responsibility for environmental protection, reproduction and wise use of natural resources. Since 1991 more than 25 codes and laws as well as numerous by-laws and regulations have been adopted to protect the environment.

Land Code (2001) The Land Code defines the main directives for management use of the state lands, included those allocated for various purposes, such as agriculture, urban construction, industry and mining, energy production, transmission and communication lines, transport and other purposes. It also establishes the measures aimed to the lands protection, as well as the rights of state bodies, local authorities and citizens towards the land.

"The procedure of impact assessment on land resources caused by economic activities” is approved by the RA Government N 92 decree as of 25.01.2005.

The indicators of pollution of land resources and their requirements are regulated by N 01 - N order established by the Minister of Health Care as of 25.01.2010: “Hygienic norms N.1.7.003- 10 of sanitary rules and requirements regarding the land quality."

Water Code (2002) The main purpose of the Water Code is to provide the legal basis for the protection of the country’s water resources, the satisfaction of water needs of citizens and economic sectors through effective management of water resources, and safeguarding the protection of water 5 resources for future generations. The Water Code addresses the following key issues: responsibilities of state/local authorities and public, development of the National Water Policy (2005) and National Water Program (2006), water cadastre and monitoring system, public access to the relevant information, water use and water system use permitting systems, trans-boundary water resources use, water quality standards, hydraulic structures operation safety issues, protection of water resources and state supervision.

Mining Code (2011) The code defines principles and rules of mining in the RA, the relations related to preservation and use of the deposits, conditions and requirements of efficient use, complex use and preservation of deposits, security of mining and protecting the environment from its negative impacts, as well as protection of rights of the state, citizens and users of deposits. According to the Code, natural deposits areas under the exclusive ownership of the state. They may be given out for use for a certain period of time, and cannot be privatized. The law also determines conditions, requirements and peculiarities of the natural resources and deposits. It also establishes payment principles, compensation, monitoring, and limitation for mining activities.

Law on Environmental Impact Assessment (1995) The Law on Environmental Impact Assessment (EIA), passed in 1995, provides legal basis for implementation and introduction of state expertise of planned activities and concept frameworks as well as presents the standard steps of the EIA process for various projects and activities in Armenia. It establishes the general legal, economic, and organizational principles for conducting mandatory state EIA of various types of projects and “concepts” of sectoral development. The Law also stipulates provisions directly related to project sector, particularly in the Article 4 “Intended Activities Subject to Expertise” the Law enumerates the types of planned activities subject to environmental impact assessment: In the town-planning sector the construction of buildings, constructions, complexes exceeding the threshold is subject of environmental impact assessment (“thresholds” were set by the Governmental Decree N193 issued on March 30, 1999). Construction of hospital (including the boiler house) is subject to EIA (as it exceeds the threshold of 1500m2). The Law forbids any economic unit to operate or any concept, program and plan to be implemented without a positive conclusion of an EIA. In addition, an EIA may be also initiated for projects that do not meet the “threshold” requirements. According to the Article 4, such right was given to local authorities, ministries, local communities and NGOs. Other national legislation that determines the “special status” of a particular territory may also trigger a review of environmental impact. The Ministry of Nature Protection can initiate a review of environmental impact when it deems it to be necessary. The EIA Law specifies notification, documentation, public consultations, and appeal procedures and requirements. The Law on EIA law also provides for public involvement and participation. The Law demands that for the operation of any economic unit, or implementation of a plan or programs, a positive conclusion on an environmental impact assessment must be obtained from the State Environmental Expertise State Non Commercial Organization of the RA Ministry of Nature Protection.

The Law on EIA is generally consistent with the EIA approaches followed by international conventions and development assistance agencies (e.g., World Bank, ADB, USAID, EU, etc.). The law had a significant role in the establishment of environmental impact assessment system and development of preventive measures. However, the latter was adopted in the initial stage of economic reforms and it does not meet the existing requirements. Among a number of gaps within the law, the key one is that there is no classification and regardless of the level of impact the same procedure and examination dates are exercised for all the projects. In February of 2012, the National Assembly adopted a new law regarding the law change that was not signed by the 6

President and was returned to the National Assembly for future review and editing. At the present, the RA Ministry of Nature Protection discusses the necessity of developing a new bill.

Law on Ensuring Sanitary-epidemiological Security of the RA Population (1992) The Law “On Ensuring Sanitary-Epidemiological Security of the RA Population” was adopted in 1992, which sets legal, economic and institutional bases for ensured sanitary and epidemiological safety of the population, as well as other guaranties provided for by the State to exclude influence of adverse and hazardous factors on human organism and ensure favorable conditions for vital capacity of the present and future generations.

Law on Atmospheric Air Protection (1994) The objective of the law is to provide the cleanness of the atmospheric air, elimination and prevention of the negative impact on the atmospheric air, as well as regulation of public relations in this field. The law defines norms of permissible amount of concentrations and physical negative impact as well as norms of permissible pollution from movable and unmovable sources. The law regulates also the emissions from vehicles and other transport measures, defines the permissible designs, locations and operation of air polluting industries and constructions, as well as the requirements on maintenance of air quality in case of developing cities and residential areas. The law defines measures aimed at the protection of air quality, while implementing various types of activity. The organizations that emit wastes are obliged to take measures to decrease the impact of emissions, prevent the reasons of negative impact. Limitations /ban of implementation of the activities, termination, prevention/ are also included in case of violation of the defined requirements and conditions. It also refers to the stages of planning, allocation, and building, enhancing and operating the organizations, institutions, objects that have an impact. The law defines the State control over the quality of ambient air, as well as the mechanisms for responsibilities for the violation of the provisions, reimbursement, etc.

To comply with the requirements of this law RA Government adopted regulations “on rules of state registration of adverse impacts on atmospheric air” (dated 22.04.1999 N259)”, and “on issuing the permits for allowing emissions and on norms for the maximal allowable concentration of substances polluting atmospheric air and maximal allowable levels of physical adverse impacts” (dated 30.03.1999 N192). RA Government also approved the regulation “on establishment of norms on maximal allowable concentrations (MAC) of atmospheric air pollutants in urban areas and on maximal allowable norms of the dangerous substances contained in the emissions of the auto transport operated in the territory of RA” (dated 2.02.2006).

Law on Medical Care and Services to the Population (1996) The Armenian Law on Medical Care and Services to the population establishes the legal, economic ad financial guidelines for medical care and service delivery, which ensures the realization of people’s constitutional right to preserve their health.

Law on the Protection and Use of Fixed Cultural and Historic Monuments and Historic Environment (1998) The Law on the Protection and Use of Fixed Cultural and Historic Monuments and Historic Environment was adopted by the National Assembly on November 11, 1998. It provides the legal and policy basis for the protection and use of such monuments in Armenia and regulates the relations between protection and use activities. Article 15 of the Law describes procedures for, among other things, the discovery and state registration of monuments, the assessment of protection zones around them, and the creation of historic-cultural reserves. Article 22 requires the approval of the authorized body (Department of Historic and Cultural Monuments 7

Preservation) before land can be allocated for construction, agricultural and other types of activities in areas containing monuments.

Law on Environmental and Nature Use Charges (1998) The law regulates calculation of payments for various types of nature protection and nature utilization activities (hereinafter payments), the order of their processing, liability in case of violation of the law, and other relations. According to the Law Nature Protection payments are compulsory and generate funds for implementation of environmental programs which are defined for pollution of environment (air and water basin) with harmful substances, for allotting production and consumption wastes in the environment according to the specified procedure, and for goods harmful for the environment, and nature utilization payments are paid to the State budget, which is aimed at effective and targeted use of State-owned natural resources, as well as for creation of equal conditions for users of natural resources of different quality, which are defined for payments for water utilization, payments for exhausted hard mineral wealth supplies, extracted supplies of subsurface sweet water and mineral water and salt, and for consumption of bio-resources. The rates of nature protection fees are paid by the RA Law “on Rates of Nature Protection Payments”.

Law on Rates of Nature Protection Payments (2006) The law sets rates for nature protection payments and the mechanism of their calculation. The law specifies the rates of the payments for emission of harmful substances to the air from the cars, tracks used and owned by RA individuals and legal entities. Higher rates are set for Yerevan and specially protected areas. The law defines the rates of the payments for emission of harmful substances and combinations to the water basin. Higher coefficient is used for calculation of emissions in Lake Sevan, Hrazdan and Getar rivers. It also provides for the rates of the payments for environmental and consumers’ wastes, according to the danger category and allocation place. In addition to the above mentioned requirements the law also identifies the rates of the payments for 52 goods harmful for the environment, by percentage proportionality.

Law on Flora (1999) The law defines RA state policy in the field of maintenance, protection, usage and regeneration of flora. The law defines objectives of flora examination, state monitoring, state inventory, requirements and approaches of red book preparation on flora, conditions, peculiarities, limitations of allocation of flora objects for purposeful usage, basis of termination of the right to use, provisions on flora maintenance, and economic encouragement of usage and implementation of supervision. The law also defines the rights and obligations of the state governance and local governmental bodies in the field of flora maintenance, protection, reproduction and usage, mechanisms of state inventory, principles of deciding their indicator.

Law on Fauna (2000) The law defines RA state policy in the field of maintenance, protection, usage and regeneration of fauna. The law defines the objectives of survey of the fauna, state monitoring, state inventory, requirements and approaches of red book preparation on fauna, conditions, peculiarities, limitations of allocation of fauna objects for purposeful usage, basis of termination of the right to use, provisions on fauna maintenance, and economic encouragement of usage and implementation of supervision. The law also defines the rights and obligations of the state governance and local governmental bodies in the field of flora maintenance, protection, reproduction and usage.

Law on Wastes (2004) The law regulates legal and economic relations connected to the collection, transfer, maintenance, development, reduction of volumes, prevention of negative impact on human 8 health and environment. The law defines the status of wastes, the main principles and directions of state policy, the principles of state standardization, inventory, and introduction of statistical data, the implementation of their requirements and mechanisms, the principles of wastes processing, the requirements for presenting wastes for the state monitoring, activities to decrease the amount of the wastes, including nature utilization payments, as well as the compensation for the damages caused to the human health and environment by the legal entities and individuals, using the wastes, as well as requirements for state monitoring and legal violations. The law defines the rights and obligations of the state governmental and local governmental bodies, as legal entities and individuals.

Law on Environmental Oversight (2005) The Law regulates the issues of organization and enforcement of oversight over the implementation of environmental legislation of the Republic of Armenia, and defines the legal and economic bases underlying the specifics of oversight, the relevant procedures, conditions and relations, as well as environmental oversight in the Republic of Armenia. The existing legal framework governing the use of natural resources and environmental protection includes a large variety of legal documents. Governmental resolutions are the main legal instruments for implementing the environmental laws. Environmental field is also regulated by presidential orders, Prime-Minister’s resolutions and ministerial decrees.

Law on Specially Protected Natural Areas (2006) The law defines legal basis and relations of state policy for development, restoration, maintenance, reproduction and use of natural complex and separate objects, as well as ecosystems of specially protected natural areas of the Republic. According to the law, specially protected natural areas are divided into four categories, National parks, State Reserves, Natural museums and the forth category is divided into three separate types: areas of international, republican and local importance. Law defines concepts, regimes of maintenance, principles of preparation of specially protected natural areas management plans, monitoring, calculation and state registrar, as well as the requirements of usage, limitations and principles, rights and obligations of state governmental and local governmental bodies, maintenance bodies of the protected areas, the rights public to get an information on protected areas, financial sources of protected areas, requirement of supervision and responsibility for violating the Law on Specially Protected Natural Areas.

Law on Compensation Rates for Damage Caused as a Result of Environmental infringements to flora and fauna (2005) The law defines the rates of damage compensation caused as a result of environmental infringements to flora and fauna, as well as the calculation and collection procedure of these tariffs.

The RA Health Minister’s N 138 order as of May 6, 2002 on approving N2 – III – 11.3 sanitary norms on “Noise at workplaces, public and residential buildings, and residential construction areas”.

The mentioned above sanitary norms have established the level and indices of noise exposure impact generated as a result of industrial, service and other types of activities.

The RA Health Minister’s N 01-N order as of January 25, 2010, “On approving sanitary rules and norms of soil quality hygiene requirements N 2.1.7.003-10".

The sanitary rules and hygienic norms determine the hygienic requirements of soil quality, such as the hygienic evaluation of land sanitary condition, soil quality monitoring, assessment of main 9 indicators of the sanitary condition of the soil, depending on their functional significance, as well the degree of soil pollution on land use proposals.

The RA Health Minister’s N 533-N order as of May 17, 2006, “On approving HN N 2.2.4-009- 06 vibration hygiene norms at workplaces, residential and public buildings".

The hygienic norms determine the vibration classification, regulation standards, the maximum permissible level of vibration at workplaces, as well as the permissible levels of vibration at residential and public buildings.

3.2 Permits and agreements required prior to commencement of construction works and during operation of a medical center

 Positive conclusion for construction of New Meghri Medical Center issued by State Environmental Expertise SNCO of the Ministry of Nature Protection. Such conclusion is required in accordance with the Law on Environmental Impact Assessment. A construction company is responsible for the preparation of documents necessary for environmental expertise, which include EIA report and annexes.

 Agreement from the relevant local/regional authorities (usually community administration) for disposal of excavated materials and construction wastes in the approved dump site shall be obtained by Construction Contractor prior to transportation and disposal of construction concrete rubbles, debris and spoils as well as excessive excavation materials in such dump sites; Compulsory payments for the emission of harmful substances, surface and underground water pollution with wastewater, pollution of other components of environment are calculated and paid in accordance with RA Law on Environmental and Nature Use Charges (28.12.1998) and RA Law “On Rates of Nature Protection Payments” (dated 19.04.2000). According to the mentioned law the environmental payments are made by the companies which are polluting the environment. These companies are responsible for calculating the amounts of environmental payments are to make these payments to the State budget. Companies may have in-house environmental specialists who make the calculations, or may hire external consultants for this purpose.

For the operation phase of the project, the following requirements apply:

 Develop draft MPE normative for the operation of a boiler house of the Medical Centre and submit it to MNP for approval.  Develop draft water consumption standards and MPD normative for the Medical Centre and submit it to MNP for approval.  Develop technical passports for medical wastes and submit them to MNP for clearing their disposal. A waste passport contains data on the composition, quantity, hazardousness, as well as information on its storage, transportation or neutralization methods.

According to the above referenced legislation all of the above mentioned documents must be developed by companies which pollute the environment. In this particular case it must be done by specialized consulting companies hired by the Meghri Medical Center.

3.3 International Agreements

In addition to the above presented list of laws, numerous strategies, concept frameworks, and national programs related to the nature protection have been developed as well as a number of international agreements and conventions have been signed and ratified by the Republic of Armenia. The table below shows the list of mist relevant International Conventions and Protocols as well as their status with respect to signing and ratification by the Republic of Armenia.

Convention or Protocol, NN In Force Signed Ratified Comment Name and Place Convention on Biological Diversity, Re-registered in 1 1993 1992 1993 (Rio-De-Janeiro, 1992) UN 1993 UN Framework Convention Re-registered in 2 on Climate Change, 1994 1992 1993 UN in 1993 (New-York, 1992) Kyoto Protocol, 3 2005 2002 (Kyoto, 1997) Convention on Long-range Transboundary Air Re-registered in Pollution, 1983 1996 UN in 1997 (Geneva, 1979) Protocol on Persistent Organic Pollutants, 4 1998 (Aarhus, 1998) Protocol to Abate Acidification, Eutrofication and Ground-level Ozone, 1999 (Gothenburg, 1999) Convention on Environmental Impact Re-registered in Assessment in a Transboundary Context, 1997 1996 UN in 1997 (Espoo, 1991) 5 Protocol on Strategic Environmental Assessment, 2003 (Kiev, 2003) UN Convention to Combat Desertification, Re-registered in 6 1996 1994 1997 (Paris, 1994) UN in 1997 Convention on the Control of Transboundary Movements of Hazardous Wastes and Their Re-registered in 7 1992 1999 Disposal, UN in 1999 (Basel, 1989) Convention for the Protection of the Ozone Re-registered in Layer, 1988 1999 UN in 1999 (Vienna, 1985.) 8 Montreal Protocol on Substances that Deplete Re-registered in the Ozone Layer, 1989 1999 UN in 1999 (Montreal, 1987) Convention on Access to Information, Public Participation in Decision-Making and Access to 9 2001 1998 2001 Justice in Environmental Matters, (Aarhus, 1998)

Convention on Protection and Use of Trans- boundary Watercourses and International 1996 1999 Lakes, 10 (Helsinki, 1992) Protocol on Water and Health, 1999 (London, 1999) Table 1 3.4 The World Bank Safeguard Policies The World Bank OP/BP 4.01 Environmental Assessment is considered to be the umbrella policy for the Bank's environmental safeguard policies. These policies are critical for ensuring that potentially adverse environmental and social consequences are identified, minimized, and properly mitigated. The HPIU carries out screening of each proposed project to determine the appropriate extent and type of EA to be undertaken and whether or not the project may trigger other safeguard policies. The safeguard policies, the triggers for each policy, as well as status of their relevancy for the proposed project are presented in the table below:

Operational Policy Triggers Status Environmental If a project is likely to have potential (adverse) environmental risks and impacts Yes Assessment (OP 4.01) in its area of influence. Forests Forest sector activities and other Bank sponsored interventions which have No (OP 4.36) potential to impact significantly upon forested areas. Involuntary Physical relocation and land loss resulting in: (i) relocation or loss of shelter; No Resettlement (ii) loss of assets or access to assets; (iii) loss of income sources or means of (OP 4.12) livelihood, whether or not the affected people must move to another location. Indigenous Peoples If there are indigenous peoples in the project area, and potential adverse impacts No (OP 4.10) on indigenous peoples are anticipated, and indigenous peoples are among the intended beneficiaries. Safety of Dams If a project involves construction of a large dam (15 m or higher) or a high No (OP 4.37) hazard dam; If a project is dependent upon an existing dam, or dam under construction. Pest Management If procurement of pesticides is envisaged; If the project may affect pest No (OP 4.09) management in the way that harm could be done, even though the project is not envisaged to procure pesticides. This includes projects that may (i) lead to substantially increased pesticide use and subsequent increase in health and environmental risk, (ii) maintain or expand present pest management practices that are unsustainable, not based on an IPM approach, and/or pose significant health or environmental risks. Physical Cultural The policy is triggered by projects which, prima facie, entail the risk of No Resources damaging cultural property (e.g. any project that includes large scale (OP 4.11) excavations, movement of earth, surface environmental changes or demolition). Natural Habitats The policy is triggered by any project with the potential to cause significant No (OP 4.04) conversion (loss) or degradation of natural habitats whether directly (through construction) or indirectly (through human activities induced by the project). Projects in Disputed The policy is triggered if the proposed project will be in a “disputed area”. No Areas (OP 7.60) Projects on If the project is on international waterway such as: any river, canal, lake, or No International similar body of water that forms a boundary between, or any river or body of Waterways surface water that flows through, two or more states ( or any tributary or other (OP 7.50) body of surface water that is a component of this waterway); any bay, gulf, strait, or channel bounded by two or more states or, if within one state, recognized as a necessary channel of communication between the open sea and other states-and any river flowing into such waters. Table 2 12

The Project is classified as the Environmental Category “B” in accordance with the World Bank OP/BP 4.01.

3.5 Administrative Framework

This section reviews the roles of government agencies that may have involvement in the current project, primarily but not exclusively from an environment perspective.

Ministry of Nature Protection The Ministry of Nature Protection (MNP) is responsible for the protection, sustainable use, and regeneration of natural resources as well as the improvement of the environment in the Republic of Armenia. In those areas, the MNP’s authority includes overseeing national policy development, developing environmental standards and guidelines, and enforcement. The MNP implements those functions through the following structural departments:  Normative-methodological Department o Division of Legislation o Division of Standards and Technical Regulations  Department of International Cooperation  Department of Environmental Protection o Division of Biodiversity and Water Resources Protection o Division of Land and Atmosphere Protection  Department of Hazardous Substances and Waste Management  Department of Nature Protection and Environmental Economics  Department of Underground Resources Protection  Department of Meteorology and Monitoring of Atmosphere Pollution

The MNP also undertakes several functions through the following key detached divisions and subordinate bodies:

. Water Resources Management Agency WRMA is the key institution responsible for the water resources management: development of National Water Policy and National Water Plan; classification of water resources by their purpose usage; participation in water standards development and supervise their application, issue water use permits, etc.

. State Environmental Expertise SNCO (conduct environmental assessments, issue conclusions) . State Environmental Inspectorate (includes 11 Regional Environmental Inspectorates: oversee the implementation of legislative and regulatory standards in natural resources protection, use and regeneration. It also conducts environmental inspections at worksites for control of environmental measures and valid permits.) . Environmental Impact Monitoring Centre (collects water quality data from 131 sampling points) . Armenian State Hydro-meteorological and Monitoring Service SNCO (operates 97 active hydrological stations) . Bio-resources Management Agency

Ministry of Energy and Natural Resources The Ministry of Energy and Natural Resources (MoE) is a state body of executive authority, which elaborates and implements the policies of the Republic of Armenia Government in the energy and natural resources management sector. The MoE implements the functions related to natural resources management through the following structural departments: . Geological Agency . Mineral Resources Agency Ministry of Healthcare The Ministry of Healthcare (MoH) is a state body of executive authority, which elaborates and implements the policies of the Republic of Armenia Government in the healthcare sector. The MoH implements the functions related to development and organization of implementation of healthcare management policy and state projects, development and approval and sanitary norms and rules, drafting as well as oversight over implementation of laws and regulations related to healthcare sector.

The MoH has the following separate divisions and state agencies:  National Healthcare Agency ((includes 11 regional branches);  National Hygiene and Anti-Epidemiological Surveillance Inspectorate (operates through number of branches established in Yerevan and regional centers)

The Ministry of Health (MOH) is designated by the Government as the responsible agency for the Project. The Ministry is supported by the Health Project Implementation Unit (HPIU) - the coordination unit for the on-going Armenia Health System Modernization Project. The HPIU will be responsible for overall implementation of the project, including its environmental compliance.

4. Legal and Administrative Framework 4.1. Location Description City of Meghri is located in the southern part of the RA Syunik marz, 373km away from Yerevan city. From geomorphologic standpoint, the planned area of the hospital is located on the irrigated gorge boundaries of Araks River which partially covers fluvial stratification, and weathered-eroded slopes.

Geological structure of the region is formed from rocks from various periods "from Paleozoic to Cainozoic" and of different origin: sediment, volcanic, volcanic-sediment, metamorphic formations, which are intensively mixed and displaced due to many different tectonic movements, and are cut by deep intrusive rocky formations of different age.

The Paleozoic formations are represented by upper Devonian period carbon and Permi period limestone rocks. The Mesozoic period is represented by upper Jurassic calcium carbonate volcanic and terrigenous sediments. Cainozoic formations are most abandoned and represented by terrigenous tufa formations and limestone, as well as by middle eocene age volcanoes sediments.

The Quaternary age alluvial and pro-alluvial formations are abandoned on river deposited plains.

The region is included in Tsakhkuniats-Zangezur (Meghri) anticlinorium zone, characterized by elevated basement. The zone is limited from north-east by Shirak-Zangezur, and from south- west by Ani-Ordubad tectonic abyssal fracture. The main mountain formation processes are registered in Pyrenean folding period (Eocene-Miocene), and the erosion surface is formatted in middle-upper Pliocene, partially in Quaternary age.

The soils are river plain deposited. The soil formatting rocks are contemporary riverbed and pro- alluvial and alluvial-pro-alluvial deposits.

The level of soil erosion makes 1%.

The possible intensity of earthquakes in the above mentioned region makes 6-8 magnitude, the maximum horizontal accelerations are 0,3-0,5 g (data provided by the National Seismic Protection Service).

The Zangezur Mountain Range stretches 140 km from Amulsar to Meghri canyon. The highest southern part has rocky, hard to reach, steep slope peaks, named Kaputjugh, Siskatar, Gazanaler. The schematic maps of the region’s folded–fractured morphological mountains and surface slope angels are presented below in Figure 1.

Figure 1

The planned area for the construction of Meghri Medical Center is located in the city limits, in urban environment and occupies 1.2069 hectare of area. The presented land is a communal property and was allocated for construction through the Meghri municipality's decision (see annex 8). The neighboring lands are privatized by a number of Meghri citizens.

The immediate area is deserted, mostly treeless. There are a few bushes on the borderlines of the designated area. Separate portions of the area are covered with grass.

There are orchards adjacent to the area, other deserted areas and to the east there is an unused building. The area is limited by Meghri-Yerevan-Agarak highways on its three sides. Meghri River flows by the northern border of the area, and Araks River flows by the eastern and southern directions, on the opposite side of Meghri-Agarak highway. Below are the images of the area.

Picture 1

Picture 2

4.2. Climate Syunik marz is distinguished by the wide range of climatic zones. Here is located the hottest place in the republic, the Meghri low zone. The annual solar isolation varies in the range of 2120 to 2660 hours; the number of sunless days makes 21-59. The average air temperature in January 16 is 0.9C (Meghri) and in July-August +25.4C. The maximum air temperature observed in Meghri was +41C. The schematic map of climatic zones spreading is presented in Figure 2.

Figure 2 4.3. Water Resources From the southern side the marz is bordered by Araks River, which has substantial influence on the process of forming the region's environmental and climatic conditions. The rest of region's rivers are scarce and fast flowing. The largest river is Meghri.

The descriptions of Meghri River’s multiannual average flow, as well as the annual maximum and minimum discharge are presented in the table below.

Flow Outflow, Annual flow, Flow layer River module, Flow rate m3/sec. million m3 height, mm l/sec. km2 Meghri 3,28 102 11,8 372 0,57 Table 3

Annual average Maximum outflow, Minimum outflow, River outflow, m3/sec. m3/sec. m3/sec. Meghri 3,28 87,5 0,94 Table 4

According to the data provided by Environmental Impact Monitoring Center SNPO of the RA Ministry of Nature Protection, the samples taken from Meghri River reveal that BOD5, nitrite, aluminium, copper ions concentration were exceeding maximum allowable norms. The status of river's pollution is described in the table below.

Number of Excess of average Number of Name of MPC Number of cases exceeding concentrations from observatory exceeding notes MPC MPC (multiply) point indicators

aluminium 4 1.4 1 (89) 9 copper 10 3.0 aluminium 5 1.6 2 (90) 11 copper 12 6.0 Table 5 The underground waters are located deeper than 3.0 m, though in some places the variations of its levels are possible up to 0.6m.

4.4. Air Quality

The air basin pollution depends on two factors: the meteorological conditions of a specific locality and the amount of emissions emitted by various facilities/objects.

Taking into account the fact that there are not many industrial and processing companies in Meghri, the main sources of pollution of the community’s air basin are transportation and heating systems during the cold weather.

The air pollution is characterized by background concentrations level of different pollutants. The air pollution control of residential areas on the territory of the RA is implemented by Environmental Impact Monitoring Center SNPO of the RA Ministry of Nature Protection by the means of observation stations located in the settlements.Though permanent observation stations are located only in Yerevan, Vanadzor, Ararat and Hrazdan cities, the background concentrations of atmospheric air pollutants in other settlements are determined by a table developed by SNPO based on the number of people residing in this area.

3 Number of population Background concentrations of determined substances (mg/m ) (thousand) Dust Sulfur dioxide Nitrogen dioxide Carbon oxide 50 -125 0,4 0,05 0,03 1,5 10 - 50 0,3 0,05 0,015 0,8 < 10 0,2 0,02 0,008 0,4 Table 6

Below are the background pollutants indicators and their comparisons with average daily maximum allowable concentrations determined for settlements.

N Name of hazardous Average daily Background Pollution according substances MPC,mg/m3 pollution, mg/m3 to MPC, % 1 Dust 0.3 0.2 66.7 2 Sulfur dioxide 0.05 0.02 40.0 3 Nitrogen dioxide 0.04 0.008 20.0 4 Carbon oxide 3.0 0.4 13.3 Table 7

4.5. Biodiversity

Flora Kinds of natural vegetated areas: xerophyte sparse forest vegetation. Having mixed juniper together with Juniperus polycarpos C. Koch, J.oblonga Bieb., J. hemisphaerica J. et C. presl., J. foetodossima Wild, J.Sabina l. Ephedra procera Fisch. Et Mey.

Foliate mixed together with Paliurus spina-christi Mill., Spiraea crenata l., Amugdalus fenzliana (Fritsch) Lipsky, Pistacia nutica Fisch. et Mey. Celtis glabrata Stev. Ex Planch., Cerasus incana (Pall.) Spach, Pyrus salicifolia Pall.

Among usable wild vegetation species are small Centraurium erythraea and Rubia tinctorum (the National Atlas, State Committee on Cadastre and National Academy of Sciences, Volume 1 page 80); from endemic species, Raddey pear (Pyrus raddeana), Nairyan almond (Amigladus nairica), Takhtajyan dandelion (Schophularia takhtajanii).

Among the species registered in the Red Book are Caucasian lotus (Diospyros lotus), and Myotis Schaube Kormos.

The presented area was used for agricultural purposes for a number of years, during which the natural cover was violated. Representativeness of wild fauna and wildlife are lacking here.

Wildlife Vertebrates: rana ridibunda, red-rumped lizard, common adder, house sparrow, gray crow, magpie, common and public hamster, gray rat, fox, wolf, marten, weasel, wild boar. Invertebrates: earthworm, ant, bee, cricket, grig, grasshopper, bug, butterfly, cabbage butterfly, mosquito (citation from the National Atlas, State Committee on Cadastre and National Academy of Sciences, Volume 1, page 82-84). In the classified of endemic species are Armenian Phytodrymadusa (Phitodrymadusa armeniaca Rme), Sphaerobothris aghababiani Volk. & Kalashian, Erisydnus helibeocci Tejap. & Herp. 19

Myotis Schaube Kormos specie is registered in the Red Book.

No wildlife is registered on the land plot allocated for the construction of the Meghri Medical Center and in its immediate surroundings.

4.6. Specially Protected Nature Areas

So as to protect and conserve the landscape and biological diversity in the region a number of specially protected natural areas (SPNA) have been created, Boghakar State reserve is the nearest one and 8-9 km away from Meghri city. Reserve was established in 1989, occupies 2728 hectares. The 8-9 km distance from the mentioned state reserve, as well as the calculated parameters of construction and hospital operation allow us to conclude that the reserve will not be subjected to any impact which can be defined or measured.

5. Social and Economic Conditions

The RA Syunik region is located in the south of the Republic of Armenia. The marz is bordered with the RA Vayots Dzor Region on the north, and from the south it borders with Islamic Republic of Iran (the border length is 42 kilometers), on the west border is Nakhichevan and on the east border is Azerbaijan.

The RA Syunik region occupies 15.1% of the RA territory. Total area of Syunik marz is 4506.0 square km. Agricultural land - 333598.0 ha, including arable area - 43790 hectares The marz center is Kapan city Urban communities - 7 Rural communities - 102 Rural settlements - 127 As of January 1, 2011 the number of population (permanent) - 152.9 thousand people including urban - 103.5 thousand people rural - 49.4 thousand people A highway connecting Armenia to Iran passes through Syunik marz. The marz’s share of economy of the total RA economy makes: - Industrial production - 18.3%, - Agricultural products - 5.7%.

Although Syunik region occupies a position possessing strategic and geopolitical significance, has rich resources of natural raw materials and great production potential, as well as is one of the major administrative and economic regions, at the same time remains relatively uninhabited and weakly appropriated from the economical standpoint, which is partly due to the great distance from the capital and the absence of alternative means of transportation. The population of Meghri city by years makes:

Name of settlement Number of permanent inhabitants, person 01.01.2010 01.01.2011 01.04.2012 Meghri 4775 4789 4800 Table 8

Brief description

Meghri is situated on the right and left banks of Meghri River, called Big and Small quarters. The city is bordered by state borderline and mother Araks River from the Islamic Republic of Iran. The city's climate is subtropical and dry. The spring in Armenia starts in this place and the autumn spends its last days here. Summer is hot, though winter is not snowy. The height from sea level is 610 m.

A Brief Historical Overview

Meghri in the past was the "Sun" province of Goghtan world that is mentioned yet in ancient times. In the course of history Meghri from time to time was under the dominance of Seljuk Turks, the Mongol Tatars, but always remained steadfast.

In 1828, Meghri was included in Karabakh province, and in 1868 it compounded a part of Yelizavetapoli’s Zangezur province. After the Soviet dominance was established, on 9 of September, in 1930, Meghri region was formed having Meghri as its center. Agulis socio- cultural life had a great impact on the cultural life and livelihood of Meghri.

Education, Culture

In 1881 a group of young people who studied abroad together with the initiative of Meghri youth and in partnership with village men opened a bisexual parochial school in Meghri village. At present, there are 2 secondary schools in the city. A stadium and 2 swimming pools are situated on Adelyan Street of Meghri city in the vicinity of a cultural complex. Once a village, then town Meghri has received a status of city starting from 1984.

Economy

A resident of Meghri has always been known as a noble gardener. Aromatic and fresh fruit grow here, in recent years together with figs, pomegranates, quinces, grapes, peaches; also the cultivation of subtropical crops such as grapefruit, kiwi, olives and etc. has increased. Currently, there are wine and canned food factories operating in the city.

The only functioning construction company is "Meghri Chanshin Enterprise" LTD. ArdshinInvest and VTB-Armenia banks operate in the city. "Beeline", "VivaCell-MTS" and "Orange" telecommunication organizations provide telephone and internet connections. Besides the ancient amphitheater view of the city, 6 ancient (11 century) fortresses located on mountainous gorges, a boscage of centuries old platans and 17-century old buildings: St. Mariam, St. Hovhannes, Sargis churches and Anapastanach monastery (the latter is in emergency state) add a unique charm to city of Meghri.

Land and other natural resources

The total area of land is 3201 ha, including: - Agricultural land, 1856 ha, of which: - arable land makes 77 ha, 78 ha of perennial nursery, meadows are 2 ha, and 1699 ha of other land, - areas of residential settlements are 223 ha, 21

- manufacturing, mining and other industrial land makes 105 ha, - energy, transport, communication and utility infrastructure facilities occupy 18 ha of land, - 906 ha of land designated for specially protected areas, - 76 ha for special needs, - water land makes 18 ha.

6. Project Description

Architectural planning and functional solutions

The hospital building will be a two-storied structure having 51.0 meters x 51.0 meters of core size, internal yard (18.0 x 18.0) and a basement. The hospital will have 4 entries for ambulances, reception, infectious and administrative departments. The number of hospital beds will make 45, including 5 beds for intensive treatment. Reception, the first medical aid department and X-ray section are designed to be on the first floor, as well the administrative, economic and infectious departments will be on this same floor. The infectious department will be separated from the general area by coded door. The building will be equipped with two elevators and three stairways. It is designed to have two entries to the outside area from the basement.

On the second floor there will be surgical, intensive care, therapeutic and pediatric departments. In addition, it is designed to have on this same floor the department of obstetrics and gynecology with maternity block, which is adjacent to the surgical block.

On the land designed for hospital use a boiler-house, electrical substation, diesel station, oxygen storage, underground water container, waste water treatment plant and two security posts are to be located. The area will be fenced and will have two parking lots. The access of ambulances will be carried out by two pantuses. The space free of buildings and roads will be landscaped and trees planted.

Water supply

It is planned to have water pipes providing for the hospital, a water basin for daily regulatory works, internal water supply and sewerage networks, pumping station and sewage biological cleansing plant.

The water supply of the hospital will be carried out by the existing 50 mm water line, and by 50 mm water pipe it is brought to the hospital area. A water measurement observatory pit (valve, strainer, and gauge) is envisaged to be on the outset of the water line. The water line will be implemented by the means of polyethylene pressure pipes. As the hospital will have only 1 feeding source and because it lacks to provide 10 l/sec. water amount required for external firefighting, so as to ensure a continuous water supply it is planned to have a daily regulating water basin (enough volume to provide for 3 hours fire-fighting and 3 days emergency situations/accidents). A pumping station is planned to be in the boiler-house building. The pumping station is provided with water from the main water source, which bypasses DRR. The scheme of the pumping station and corresponding valves enable to use the DRR stored fire- fighting water amounts and vice versa for domestic purposes when there is a high necessity. The boilers supply is implemented through a pump.

The water required for external firefighting makes 10 l/sec. There is a fire-fighting network designed in the hospital area and on the envisaged two observatory pits fire-fighting hydrates are installed. 22

Sewerage

The hospital wastewater will be disposed by gravity method. Sewage collection is to be implemented by the means of polyethylene non-pressure D = 150 mm pipes. Where there are network nodes on the changing locations of horizontal and vertical declivity it is planned to have observatory pits from concrete prefabricated elements.

Since there is no sewage line and treatment plant in the region, according to the design it is envisaged to have a local treatment plant for cleansing the disposed wastewaters from the hospital, and at this plant the mechanical and biological sewage cleaning will take place.

Biological treatment plant

The biological treatment plant will consist of the following components:  general blending reservoir  1 digesters  separator  pump  compressor  sludge collector

The wastewater treatment plant estimated productivity makes 16m3/day. The plant’s external size is 2x2x6m. In absence of the regulations for the quality of the treated wastewater in the Republic of Armenia, international quality standards for discharge (the World Bank environmental guidelines and EU Urban Wastewater Treatment Directive) were used to set standard requirements for a treatment unit to be installed at the Meghri Medical Center.

Wastewater Treatment Requirements Parameter Raw Sewage - range Treated Effluent Standards Strong Moderate Mild World Bank UWWT/ WFD* UWWT/ WFD* Parameters of Env. (2,000-10,000 (>10,000 p.e.) recommended Guidelines p.e.) for Treatment plant BOD5 (mg/lO2) 25 Biochemical (70-90% 25 350 250 150 50 (70-90% influent 50 oxygen demand influent reduction) reduction)

COD (mg/lO2) 125 125 Chemical 740 530 320 250 (70% influent (70% influent 250 oxygen demand reduction) reduction) TSS (mg/l) Total 35 35 450 300 190 50 (90% influent (90% influent 50 Suspended reduction) reduction) Solids Total P (mg/l) 2 Phosphorous 23 16 10 2 - (80% influent 2 reduction) Total N (mg/l) 15 Nitrogen 10 10 80 50 30 - (70-80% influent (Ammonia) reduction)

* European Union’s Urban Wastewater Treatment Directive Table 9. Wastewater treatment requirements

During the operation of the treatment plant the sludge will be produced which is a high quality fertilizer and can be used for in the agricultural areas surrounding the Medical Center. The annual volume of sludge is expected to make 320-400 kg. Once in a quarter 80 - 100 kg of dried biomass may be provided to the neighboring farmers for applying to the fields. Prior to handing out the sludge to farmers, it must be tested by Sanitary Laboratory of Syunik regional State Hygiene Antiepidemic agency and certificate be issued on the safety of its application. In case of no farmers’ demand for the sludge, it will be stored nearby the treatment plant in a separated area and after climatic drying will be disposed in the municipal landfill. Dimensions of the sludge drying plot will make 4 x 3 x 0.15 m, will have a non-permeable concrete bottom and reliable roofing.

The processed wastewater can be released into the natural environment. However, volume of the discharge should be less than the natural river flow by multiple times. Taking in consideration that in summer months the flow of the Meghri River is extremely decreased, release of the treated waste water into it is not advisable. Therefore, following professional recommendation (John Malmborg, Architect, M.A.A, Senior Consultant, Charlottenlund, Denmark) the design incorporated construction of a sand soak pit for the absorption of the treated waste water. The dimensions of the sand layer will be 6 x 3.2 x 2.3 meters. Soil tests carried out on site showed that the ground is permeable and has the capacity to soak away the required volume of water.

Heating and hot water supply

It is planned to have a boiler-house for providing the heating and hot water supply, where two Q = 370 kW installed capacity water heating boilers will be installed. The boiler will be operated on the natural gas, and in emergency cases - on the diesel fuel.

Power supply

The electricity supply will be carried out by "AEN" CJSC system, and for that purpose an electrical substation is designed. CJSC “AEN” (Electric Networks of Armenia) is mainly engaged in regulated distribution and sales of electric energy. The company has an exclusive license for distribution of electric energy within the Republic of Armenia.

The power transformer (160kVA) is planned to be installed at the substation, which weight is 890kg, oil capacity is 205 l. The transformer installation location is furnished with the oil collection system, which volume makes V + 0.1V, in this case 225 m3, which will allow to collect the entire volume of oil in case its emergency leakage. The oil refilling, exchange and neutralization in emergency cases will be implemented by AEN Company on contractual basis. The AEN Company has the appropriate technical means, and specialists and such practice is widely used. For transformer oil AEN company utilizes oil types that do not contain PCBs.

During hospital emergency disconnections from electricity supply and so as not to interrupt the normal operation of the hospital activities, it is planned to have a diesel plant, which includes diesel generator and diesel fuel storage. Below are the situation plan and layout.

Figure 3

Figure 4 25

7. Project Alternatives

7.1. “No Action” Alternative “No Action” alternative addresses the situation with no Project implemented.

The Meghri region currently has hospital facilities on two locations – in Meghri and in Agarak cities.

Meghri Medical Center In Meghri, the medical center functions on two locations—in polyclinic in the city center and in hospital on another location, both in poor building conditions.

The hospital is located on a territory of 0.92 hectares, is constructed in 1960 and consists of 15 buildings, including two medical sub-buildings—the main hospital and infectious diseases sub- building, and 13 support buildings, including the morgue, laundry, boiler house, garages, storehouses, electrical substation, etc.

The main hospital building is a partially three storied 2949 square meters stone building. The one-storied infectious diseases building occupy 549 square meters and are vacant of medical services. All buildings are in poor conditions and need total capital renovation, replacement of roof, systems of electricity, sewage, water supply and heating. The road to hospital is in poor condition, too.

Meghri polyclinic is in the very center of Meghri city, well accessible for the population of the region. The polyclinic building consists of 6 floors of 2010 square meters in total. The sixth floor of the building is rented out to the Meghri branch of the Syunik marz Sanitary and Anti- Epidemic Station. The building conditions are better as compared to hospital but it is in need of renovation, too.

Meghri Medical Center hospital delivers therapeutic, pediatric, OB/GYN and infectious diseases services. Before optimization in 2005 it had 40 beds in total, currently the number of beds is reduced to 25. The hospital activity levels are low. In spite of the reduction of the bed fund the average annual bed occupancy did not change much (25% in 2005 to 26% in 2009). The number of surgeries in the same period ranged 71-117, while of deliveries—33-52 (see annex 3 for details).

Agarak hospital is located at the distance of 11kms from Meghri. The hospital is one main building of around 3500 square meters in need of renovation. It provides the same services as Meghri hospital (therapeutic, pediatric, OB/GYN and infectious diseases treatment services). In the period between 2005 and 2009 the number of beds was 35 with the average bed occupancy of 32-36%, mainly due to services of surgical profile. Annual number of surgeries ranged 170-230, annual number of deliveries 93-138. Agarak polyclinic services are located in the same building with the hospital services.

As a whole the conditions of all existing buildings are not satisfactory and significant investment is required in infrastructure of each of them to bring them in line with modern standards of hospital and polyclinic care and create acceptable conditions of delivery of medical services to the regional population.

As to the technical capacities of Meghri region health care facilities, the inventory of the existing medical equipment indicates that all existing medical equipment items are either depreciated 26

(more than 15 years old), or not working. The furniture is also extremely worn-out and needs complete replacement in all facilities.

“No Action” alternative will lead to the following consequences:  Insufficient provision of health care services on the basis of family medicine,  Further deterioration of hospital networks in the regions,  Distribution of healthcare services in different medical centers, which reduces the efficiency and reliability of diagnostics and treatment;  Reduction of access to quality health care services provided to the population, in particular the most vulnerable groups, and  Inadequate management of public health threats,  Increase of O&M costs associated with healthcare infrastructure;  Increased migration from rural areas, and  Decline of socio-economic situation and in population welfare.

7.2. The Initial Option

According to 1911-N decree adopted by the RA government regarding the optimization of the RA marzes health care systems, it was envisaged to combine the current Meghri medical center and Agarak hospital, thus creating a single administrative unit "Meghri Regional Medical Center" CJSC in Meghri region of the RA Syunik marz. By the way, taking into account the relatively high rates of Agarak hospital’s surgical, OB/GYN and infectious diseases services, it was offered to concentrate the mentioned services in Agarak, and services of therapeutic nature in Meghri Polyclinic building, as the latter is located in the center of Meghri city and is in much more accessible place for the population. As a result, approximately 3500 square meters of Meghri current hospital building will be vacated from provision of medical services. However, such organization of hospital services considered separation of therapeutic and surgical services, which could lead to unequal access of medical services for the population of Meghri and Agarak. At the same time, replication of reception, laboratory-diagnostic and support services would have taken place, which contradicts to the basic principles of the optimization program.

7.3. The Selected Option

Taking into consideration the above mentioned circumstances, it was decided to implement a change in the optimization program envisaging the building of a new up-to-date medical center in Meghri region with optimal localization and sizes, where all medical care services will be centralized. The new medical center will have 45 beds; as a result Meghri policlinic and hospital facilities, as well as Agarak hospital building with total area of about 9000 square meters will be vacated. The newly established center will have the following services: 10 beds at therapeutic, 10 beds at pediatric, 10 beds at OB/GYN, 10 beds at surgical and 5 beds at infectious departments, as well as intensive care service.

Summary The first option does not require implementation of construction works, respectively; the impacts arising out of these activities on the environment and population are excluded. However, as noted at point b., the first option does not allow solving the basic health care and sanitation problems. Given these circumstances, as well as the fact that impacts arising in the course of construction works are short-term and do not cause violations of the effecting rules the second option was elected.

8. Environmental Impacts of the Project

The projected impact of the planned activities on the environment is presented in two stages: in the course of the implementation of construction works and operation/maintenance. Monetary damage to the natural enviornment is also calculated in satisfaction of the national legislation. Outcomes of such calculations are summarised in Annex 4. Based on these outcomes, no type potential damage from the construction and operaiton of the Meghri Medical Center amounts to the threshhold above which material responsibility of the project propoenet is triggered through the national legislation.

Environmental and social risks of the construction and operaiton of hte Meghri Medical Center are moderate and could me effecrively mitigated. Below sub-sections of the present Section 8 of the EIA report list potential impacts of both - construction and oepraiton stages, while Section 9 provides measures for their mitigation.

8.1. Construction Phase

The main environmental and social risks:

- Pollution of the air basin during drilling and loading operations, and exploitation of construction equipment engines; - Land degradation and erosion as a result of damaging the vegetated area; - Increase of the level of noise during construction equipment operation and motor vehicles works; - Nuisance to local communities due to movement of construction vehicles and machinery - Unsafe disposal of access material and construction waste - Nuisance to local agricultural land owners due to temporary storage of construction materials and construction waste - Risk of river pollution with water runoff - Risk of unsafe mining of natural construction materials

Impact on the environment during construction works

Emissions of hazardous materials originate during construction works when drilling of foundations, land mass loading, unloading and transportation takes place, as well as a result of construction equipment diesel engines combustion of fuel, laying of asphalt, bitumen works and welding.

a) dust emissions during drilling-loading works

During the drilling-loading works inorganic dust emissions are generated, mainly during drilling with excavator, removal of the priming ground, and loading of dump trucks.

b) Diesel fuel combustion products/results

The technical means envisaged for construction provision use diesel for fuel. During the combustion of diesel fuel nitrogen, carbon and sulfur oxides, as well as solid particles (soot) are being generated.

c) Welding works

Welding works are designed to be implemented on various construction sites: supporting facilities, clips and other places. AHO type welding electrodes are planned for welding, and during its use emissions such as welding aerosol and manganese oxides are being generated.

d) Emissions due to bitumen works

During bitumen laying vaporization of solvents used for diluting the bitumen take place, and as a result volatile organic compounds are being emitted into the atmosphere (VOC).

e) Asphalt laying

During asphalting after the asphalt layer is poured vaporization of solvents used for diluting the bitumen and asphalt masses take place, and as a result volatile organic compounds are being emitted into the atmosphere (VOC).

Calculations of emissions of mentioned above substances during short-term g/sec. and the entire construction period are presented in annexes. Results of calculations summarized according to the types of activities and separate substances are described below in Table 9. Characteristics of emitted substances and emission sources are shown in Table 10.

Phases of Amount of hazardous pollutions to the atmosphere, g/sec. (t/const. period) constructi Inorganic Welding Manganese CO VOC NO SO PM on works dust x 2 aerosol oxides 1 2 3 4 5 6 7 8 9 Drilling and 1.62 ------loading (0.75) works Emissions 0.44 0.103 0.5 0.048 0.052 due to - - - (0.04) (0.009) (0.044) (0.004) (0.0045) diesel fuel Welding 0.076 0.01 ------works (0.008) (0.001) Bitumen 0.041 ------works (0.057) Laying of 0.655 ------asphalt (0.25) 1.62 0.44 0.799 0.5 0.048 0.052 0.076 0.01 TOTAL (0.75) (0.04) (0.316) (0.044) (0.004) (0.0045) (0.008) (0.001)

Table 10. Amount of hazardous pollutions to the atmosphere in the process of construction

Emission Parameters of emission Parameters of Coordinates source source gasous Emissions of hazardous substances mixture Type g/sec. t/const. hour. 0 N height, Diameter V, T, C X1 Y1 X2 Y2 3 m m m /se c.

1 2 3 4 5 6 7 8 9 10 11 12 15 Unorganized 1 2.0 20.0 480.0 20 36100 21840 36120 21840 - inorganic dust 0.75 1.62 source of - carbon oxide 0.04 0.44 emissions on - hydrocarbons 0.316 0.799 the platform - nitrogen oxides 0.044 0.5 (construction - sulfuric anhydride 0.004 0.048 area) - PM 0.0045 0.052 - welding aerosol 0.008 0.076 - manganese oxides 0.001 0.01

Table 11. Characteristics of substances and sources of atmospheric emissions

Results of Estimates of Emissions’ Surface Concentrations

Impact assessment of emitted substances is done by comparing them with sanitary norms. The RA atmosphere pollution in regulated by the means of maximum allowable concentrations defined for residential areas. To implement such comparison it is necessary to calculate the dispersal of the emitted substances and concentrations being generated as a result of the dispersal.

In the process of construction, the emitted hazardous substances dispersal estimations were carried out by "Raduga" software. The data of Table 12 was used as input data. According to the realized calculations: • the coordinates of calculated points, m • emissions concentrations of hazardous substances, • direction of torchlight axis, • the wind speed (m/sec.) at which the surface concentrations reach the maximum value at the calculation point.

The results of computer based calculations are presented in annexes. The maximum level of pollution made as follows:

№ Name of pollutant Maximum pollution in Maximum pollution absolute units, mg/m3 according to MPC

1. Inorganic dust 0.076 0.151

2. Carbon oxide 0.0015 0.0003

3. Hydrocarbons 0.021 0.021

4. Nitrogen dioxide 0.003 0.035

5. Sulfur dioxide 0.0003 0.0005

6. PM 0.00045 0.003

7. Wielding aerosol 0.0005 0.001

8. Manganese oxides 0.00007 0.007 Table 12

The emissions generated during the construction works are temporary in nature and are emitted from platform sources and as seen from Table ___ as a result of dispersal the envisaged surface concentrations are significantly lower compared to the MAC values set for residential areas.

Water Resources

During construction works the water is mainly utilized for watering the construction platforms, cleaning the pipes, as well as for domestic-economic needs of the staff implementing the construction works.

The amounts of water utilized for watering are classified to irredeemable water use and losses. The water utilized for testing and disinfecting the pipes is collected in special tanker and the residual chlorine content having less than 0.5 mg/l index is used for watering purposes.

To provide for the domestic needs of the workers the construction company has accommodations equipped with bathroom and food court spaces nearby to Meghri city. The balance of utilized water and water removal during the construction is presented in the Table 13.

Water usage, m3/annually Water discharge, Purposes of water m3/annually Circulating usage Total Drinking Technical Outflow Irredeemable volumes, quality quality utilization m3/day and loss Dust catching 1872.0 1872.0 - - 1872.0 - (watering of platforms)

Testing of pipes and 6.0 6.0 - - 6.0 - disinfection

Drinking and 258.2 258.2 - 254.3 3.9 - household needs

Subtotal 2136.2 2136.2 - 254.3 1881.9 - Table 13

Land resources

The area of land envisaged for Medical Center makes 1.2 hectares. In the course of construction works the outer layer of land in some parts of the site is withdrawn and it could cause phenomena of further erosion.

In total 754.65 m3 of vegetated soil is removed and is stored in up to 50 meters away from the removed area and is later used for improving and landscaping purposes of the site.

As a result of construction works construction waste is generated, which may result in accumulation of garbage and pollution of the outer layer of the soil.

The total land mass will make 5930.0 m3, 2159.6 m3 of which will be used as backfilling. The surplus land mass of 3230.4 m3, as well as the construction waste will be removed to a special location provided by Meghri municipality. The place of landfill is provided by the municipality according to a written application presented by the construction company.

Asphalt layer will be destroyed in the process of construction works, total of 109.0 m3, which is removed to the same landfill. The asphalt layer will be destroyed along of inter-village roads, for the purpose of joining to municipal water network.

According to “Production forming on the RA territory and consumption waste list" the waste corresponds to "asphalt and asphaltic mixture residues without bitumen" type (code 31401002 03 00 4).

Noise

The technical machines used in the process of construction works generate additional noise. The specific parameters of noise generated by the technical means are presented in Table 14.

Name of technical Number of Absolute (tech. passport) Permissable level of means simultaneaously parameter of noise, dBA noise at the workplace operating dBA machine Excavator 1 99 - 102 85 Bulldozer 1 102 - 104 85 Hoisting crane 1 77 - 84 85 Dumper 2 82 – 87 85 Table 14

The level of noise is reduced if departing from the source of noise. Taking into account the distance of the residential districts from the construction site, the noise of the mentioned above technical means will not create an exceeding normative source for residential and public buildings.

8.2. Operation Phase The main environmental risks of the operation phase are: - improper operation of the boiler house; - improper operation of the waste water treatment plant; - mismanagement of medical, chemical, biological, and household wastes.

Impact on the air basin

The Medical Center’s heating system operation results at generation of hazardous substances from the combustion of fossil fuel that are being emitted into the atmosphere, thus impacting the environment.

The Medical Center’s heating and hot water supply thermal expenditures make:

Qheating = 232200 kcal / h or 270 kW h Q t.j. = 172000 kcal / h or 200 kW h

The total capacity of the boiler house will be 470 kW h.

According to the assignment for providing hot water and heating at the Medical Center, it is envisaged to have a boiler-house where two water heating boilers will be installed, to provide heating and hot water in winter, and during the rest of the seasons to provide only hot water. The main fuel used at the boiler-house is natural gas, as a back-up alternative liquid / diesel / fuel can be used only when there is emergency shutdown of the natural gas.

The exhaust gases from boilers installed at boiler-house are discharged through P250 mm, H = 8.0 m smoke pipe.

33 To mitigate the impact of the boiler-house on the environment and reduce the greenhouse gas emissions it is envisaged to install a solar water heater at Meghri city Medical Center.

A feasibility study to build a hot water supply solar system at the Medical Center was carried out by UNDP/GEF (UNDP/GEF/00035799) roject specialists.

The 30 m2 active surface of flat solar collectors system is able to provide the demand of Meghri city Medical center’s hot water supply fully throughout three summer months and partially for the remaining months. The lack of hot water during the transition times beyond the heating period is met by electrical water heaters, that are installed by volume water heaters, each having 10 kW capacity. During this period and summer months the boiler-house does not operate followed by all its consequences.

Water heating boilers are considered as additional source of thermal energy during the heating season for hot water supply. The environmental advantages of solar hot water heating are expressed by annual decrease of 6.57 tons of equivalent carbon dioxide emissions that in the course of 20-year economic lifetime of the project will make 131,4t. Correspondingly, the hazardous gas emissions, such as, nitrogen oxides emissions will reduce.

The boiler-house emissions have been calculated (see the annexes) for the use of natural gas, as well for diesel fuel in a short-term scale. The annual emissions originating as a result of natural gas combustion have been calculated considering solar collectors exploitation factor.

Characteristics of emission sources and nitrogen oxide (calculated as nitrogen dioxide) emissions according to fuel type are presented in Table 15.

Emission Height, Diameter, Speed, T0C X Y Emissi g/sec t/year Source m m m/sec on

Boiler 8.0 0.25 6.0 180 36100 21840 NO2 0.013 0.042 hause (natural gas) Boiler 8.0 0.25 6.0 180 36100 21840 NO2 0.0235 - hause

Table 15. Estimated concentrations of surface based emissions

The estimations of hazardous substances emitted and dispersed into the atmosphere realized during the boiler-house operation showed, that the expected surface based concentrations are in the range of permissible norms.

Data on maximum allowable level of pollution in case of natural gas and diesel fuel operation are shown at the below Table 16.

Fuel type Name of pollutant Maximum pollution expressed Maximum pollution in absolute units, mg/m3 expressed by MAC Natural gas Nitrogen dioxide 0.0005 0.006

Diesel fuel Nitrogen dioxide 0.001 0.011 Table 16

34 Water use Economic water supply of the drinking water of the Medical Center envisaged in the RA Syunik marz of Meghri city will be carried out from the urban water supply network (spring water sources). The water use volumes are not comparable with Meghri water consumption and cannot break the water balance.

The water supply internal network is circuit-shaped. The hot water is supplied from the boiler- house and partly from solar water heater, which are located at the Medical Center’s area. To ensure the fire safety of the area a ground fire-fighting hydrant is to be installed. The water supply and water discharge calculations are provided in the annexes. Below are the results of these calculations.

Water discharge

Given the fact that there are no sewage networks at the location, there is a need to build a wastewater treatment plant at the Medical Center. The plant will carry out the mechanical and biological wastewater treatment. According to the development project of Meghri city master plan, it is envisaged to build a sewerage system for the whole city, as well as a municipal treatment plant. In a long term, once the municipal services are provided, the cleansed outflow of the Medical Center will be sent to urban sewage network. Meantime, an autonomous sewage treatment plant will be provided for water purification and a sand soak pit will be built for the absorption of the treated outflow.

Water balance

Water consumption, m3/year Discharge, m3/year Water user Total Drinking Service Discharge Water losses water water Staff 416.0 416.0 - 407.7 8.3 Patients 3285.0 3285.0 - 3219.3 65.7 Cookong 1204.4 1204.4 - 1180.3 24.1 Laboratories 821.6 821.6 - 805.2 16.4 Laundries 324.0 324.0 - 317.5 6.5 Cleaning floors 876.0 876.0 - - 876.0 Watering of green areas 540.0 540.0 - - 540.0 Total 7467.0 7467.0 - 5930.0 1537.0 Table 17 Waste

Clinical wastes, X-ray films development solutions and waste of domestic nature (see the annexes) will be generated at the Medical Center. The surgical and organic wastes (clothes, bandages, paper containers and cardboard boxes) can be combined and sent to thermal neutralization after signing a contract with authorised organizations.

In particular, there are a few companies in the republic that possess a waste processing license and positive environmental expertise assessment that carry out clinical waste collection and burning.

Neutralization of solutions for X-ray film treatment will also implemented by organizations holding chemical waste processing license. Wastes of domestic nature will be transported to municipal landfill on the basis of a contract with Megri city garbage disposal company.

35 The transformer installation and maintenance at the Medical Center’s electrical substation is implemented by "AEN" CJSC and, respectively, activities related with transformer oils will be carried out by "AEN" CJSC. No PCB-containing oils will be in use.

9. Mitigation of the Expected Risks

For minimization of the negative impact the following shall be considered:

9.1 Construction Phase

Air Protection

- Ensure proper technical condition of vehicles and machinery; - Avoid running engines once the equipment is idle; - Water the territory, construction site and excavated soil in dry and windy conditions; - Take fire protection measures; - Use closed/covered trucks for transportation of construction materials; - Elaborate traffic regulation schedule.

Land Protection

- Store oils and lubricants in closed tanks and at specially designated place to prevent leakage and to minimize pollution of soil in case of leakage; - Establish the site for construction materials storage that will cause no damage to the vegetation cover; - Establish the sites for preliminary accumulation of excavated materials and waste that will cause no damage to the vegetation cover and other components of the environment; - Clearly designate a site for preliminary accumulation of waste and obtain formal agreement on the use of such site from Meghri Municipality; - Arrange proper transport and disposal of excavation materials and wastes to the approved dump sites designated for the specific purpose and agreed with Meghri Municipality; - Clean the surrounding area of the worksite from dust by regular water sprinkling (during warm and dry months), removal of excess materials and cleaning of sites upon completion of activities.

Water Resources

- Store oils and lubricants in closed tanks and at specially designated place to prevent leakage and to minimize pollution of surface and groundwater; - Establish a site for construction materials storage in a safe distance from the nearby river and prevent blocking the drainage water flow or adversely impacting water quality by construction run-off; - Ensure preservation of appropriate rules at the construction camp, including control over incoming and outgoing vehicles, and proper operation of drainage system.

Impact on the Flora and Fauna

- Avoid movement and parking of vehicles and construction machinery outside access roads and the construction yard in order to avoid unnecessary damage of vegetative cover;

36 - Designate specific locations for temporary on-site storage of excess material, construction waste, and construction materials, and ensure the above items are not scattered over the allocated land plot and beyond.

Noise and Vibration Disturbances

- Limit works in general, and especially application of noise generating technologies to the established working hours; - Maintain machinery and vehicles in good technical condition. - Avoid runing engines of idle machines.

Archaeological Finds

Cease the works in case of a chance find during earthworks at the construction site and provide relevant information to the State Agency for Historical and Cultural Monuments Protection and Meghri Municipality.

9.2 Operation Phase

Air Protection

- Establish adequate regime of servicing and maintenance of the boiler house operation, check technical condition of the appliances and periodically monitor emissions.

Water Resources

- Ensuring smooth operation of the waste water treatment plan through regular servicing of the unit. - Keeping sludge in a properly insulated and roofed drying platform, excluding leakage of runoff. - Aranging and maintaining effective drainage system for the collection and discharge of storm water to avoid waterlogging of the Medical Center area and the territory around it.

Waste Management

- Collect household waste in regular plastic binds and regularly dispose of at the municipal landfill. Make and maintain proper arrangements for out-transportation of waste with scavenger trucks. - Collect medical waste separately in special containers and regularly hand it over for disposal to a specially licensed entity. - Accumulate chemically active liquids, especially solutions for the processing of X-ray films, separately from other liquid waste in special containers and hand it over for deactivation and disposal to a specially licensed entity. - Disallow burning of any type of waste in open air at or around the Medical Center site.

Emergency Situations

- Maintain sufficient volume of water in storage to ensure operation of the Medical Center in case of emergency disruption of water supply and in case of fire. - Maintain sufficient volume of diesel fuel within a space excluding its operation and/or accidental spillage to the soil and providing sufficient protection from fire to ensure power supply to the Medical Center in case of emergency blackouts. 37 10. Affected Parties and Public Consultations

The city and region residents are considered to be the affected parties during the Medical Center’s construction and operational phases.

Meghri municipality informed all individuals who possess plots at the planned construction site. Other residents and non-governmental organizations were provided with the opportunity to get acquainted with the basic provisions of the planned project. On June 11, 2012 a preliminary discussion was carried out and the protocol is attached.

According to the law on "Expertise on Environmental Impact Assessment" the design documents and the EIA are submitted to the RA MNP, afterwards the client (construction company) together with the RA MNP and municipality organize public hearings, notifying in advance about it through the media channels. The EIA report should be available for all interested parties and for that purpose the report is posted on the website of the RA MNP.

11. Environmental Management Plan

The Environmental Management Plan (EMP) is developed for the Medical Center’s construction and operational phases to mitigate the negative environmental and social impact at the construction and operation phases. EMP includes information on the risks arising on different stages of the activities, the sectors affected by the risks, as well as the list of envisaged measures, implementers, responsible people and state or community control intended to reduce each affect of the impact.

11.1 Responsibilities and Institutional Arrangements

HPIU is responsible for the implementation of the EMP including obligation of qualitative and timely implementation of all mitigation measures, supervision on implementation, documentation of the results of the supervision about cases such as environmental problems connected with implementation of environmental activities and manual principles for contractors.

11.2 Responsibilities of Construction Contractor

HPIU shall obtain Construction Permit associated to construction activities. If any additional licenses, permits, consents required (e.g. inert material etc) construction company shall obtain such license, permits, and consents within its capacity (including conclusion of ecological expertise). Contractor is responsible during performance of earth works to pay special attention to archaeological fact findings and immediately inform Meghri Municipality and HPIU on any chance finds.

11.3 Monitoring of EMP implementation

HPIU carries overall responsibility for the implementation of EMP and for organizing environmental monitoring of works. Environmental monitoring of works shall be undertaken according to the Environmental Monitoring Plan attached to the present EIA report and the outcomes of monitoring shall be documented in monthly environmental supervision reports.

38 Annex I. References

1. Biodiversity of Armenia, http://www.nature-ic.am/biodiv/index%20eng.html 2. Climate Change Information Centre of Armenia, http://www.nature.am/ 3. Convention on Access to Information, Public Participation in Decision-Making and Access to Justice in Environmental Matters (1998); available online at: www.unece.org 4. Convention on Environmental Impact Assessment in a Transboundary Context (1991); available online at: www.unece.org 5. The World Bank Operational Manual. OP 4.01 6. Construction norms and regulations volume II-L.9-70 Hospitals & Polyclinics; 7. Construction norms and regulations 2.08.02-89 Public buildings; 8. Decree # 1911- N dated 02.11.06 of the Government of RA on “Optimization of the Marz Health Care Systems. 9. Environmental Impact Monitoring Centre of the Ministry of Nature Protection of the Republic of Armenia, Report on Surface Water State for 2011, Yerevan, 2012 (in Armenian) 10. Encyclopedia Soviet Armenia, Yerevan, Armenia, 1987 11. Environmental Research and Management Center of the American University of Armenia, http://enrin.grida.no/htmls/armenia/soe_armenia/english/ermcaua/ermc.htm 12. Fourth national Report to the Convention on Biological Diversity, Ministry of Nature Protection of the Republic of Armenia, Yerevan, 2009 13. Khandjyan N., Specially protected areas of Armenia, RA Ministry of Nature Protection, Yerevan, Armenia, 2004 14. RA Governmental Regulation on assessment of impact on atmosphere caused by economic activities, 25 January 2005, N91-N 15. National Atlas of Armenia, Yerevan, Armenia, 2007 16. Set of methodologies for calculation of pollutants emission into atmospheric air by different enterprises, Goskomgidromet, Leningrad, Russia, 1986 17. SNIP 1.02.01-85: Instruction on content, order of development, agreement and approval of design-tender documentation for construction of enterprises, buildings and structures. 18. SNIP 2.04.02-84: Water supply, External pipelines and structures 19. State of the Environment Report for Armenia, Year 2000, http://enrin.grida.no/htmls/armenia/soe2000/eng/ 20. Temporary methodological guideline on calculation of emissions of non-organized sources in construction industry, USSR Minpromstroy, Moscow, Russia, 1984 21. The Results of 2001 Census of the Republic of Armenia (Figures of the Republic of Armenia); State Committee on the Organization and Conduction of the RA Census 2001, National Statistical Service on the Republic of Armenia, 2003

39 22. Water Quality and Quantity Stations in Armenia, Armhydromet Agency, www.meteo.am 23. ПКТИ of Lithuania SSR Ministry of Local Industry “Package of uniform program for calculation of air pollution ” (PUPAPC) “Raduga”, 1990 24. EMEP/EEA Air Pollutant Emission Inventory Guide book, 2009 25. IFC. Environmental, Health and Safety (EHS) Guidelines 26. IPCC Guidelines for National Greenhouse Gas Inventories, 2006 27. STATISTICAL YEARBOOK OF ARMENIA. 2011. www.armstat.am 28. Marzes of the Republic of Armenia and Yerevan Sity in Figures, 2011

Annex 2. Environmental Management Matrix

Environmental Management Plan

Cost of Responsibility Activity Potential Impact Mitigation Measure Indicator of Mitigation Mitigation for Mitigation Construction Phase Provision of Delivery of substandard Purchase of construction materials from the Delivery of standard quality None Construction construction materials which may cause licensed providers construction materials carrying contractor materials risks to the safety of relevant certificates of origin constructed structure and to health of people operating it

Transportation of - Pollution due to poor - Adequate technical condition of vehicles - Vehicles and machinery found No specific extra Construction construction technical condition of and machinery in decent technical condition cost: common contractor materials and waste vehicles and movement - Confinement and protection of truck loads during inspections responsibility of of uncovered truckloads with lining - No uncovered truck loads found works contractor Movement of - Nuisance to local - Respect of the established hours and during inspections construction residents from noise and routes of transportation - No activity ongoing out of machinery dust working hours which may be disturbing for nearby population - No complaints from nearby residents

Operation of - Pollution of environment - Adequate technical condition of - Vehicles and machinery found No specific extra Construction construction with emissions and construction equipment in decent technical condition cost: common contractor equipment on site leakages  no excessive exhaust during inspections responsibility of - Nuisance for nearby  no fuel and lubricant leakage - No heavy vehicles and works contractor population - Observation of working hours machinery found operational out of the established working hours - No complaints from nearby population 41

Maintenance of - Pollution of water and soil - Cars and construction equipment washed - No direct entry of runoff from No specific extra Construction construction with oil products due to outside the construction site or on maximum car-wash to water bodies cost: common Contractor equipment operation of equipment distance from the river - No spillages of fuel and responsibility of - Damage in case of fire - Refueling or lubrication of construction lubricants found on the ground works contractor equipment and outside the construction site within and nearby the or at the predetermined arranged point. construction site - Technical order at the construction - Presence of basic fire equipment maintenance point extinguishing means on site  solid impenetrable floor or adsorbent (sand fine gravel, membrane) cover  enough area and impenetrable barriers around fuel containers - Provision of work site with basic fire extinguishing means

Earth works - Loss of vegetations due to - Topsoil removal and temporary storage at - Excess material disposed at the 1200 USD Construction ground piling and a separate place at the beginning of works agreed upon safe permanent Contractor minimization of pollution (to dispose to landfill in case of pollution storage sites with no threat of of surface water reservoirs and for re-cultivation of the land if it is erosion and no blocking of with particles good) waterways - Pollution with probably - Temporary storage of excavated soil at - No remnants of excess material contaminated soil of determined and allowed places in at the construction site upon surface and ground waters compliance with ground piling parameters. completion of works - Loss of cultural heritage - Backfilling of the excavated ground as - No damage to chance finds if needed and disposal of the excess mass to encountered the places, approved in writing. - Immediate termination of activities in case of archaeological chance finds and providing of full information to the State Agency for Historical and Cultural Monuments Protection

42 Extraction of inert - Slopes erosion and - Purchase of inert materials from the - Construction contractor (if 450 USD Construction material landscape damage existing suppliers, if there is such mining) or an external provider Contractor - River banks erosion, opportunity of inert materials able to present pollution of water flow with - Obtaining of the license for production of relevant license for mining upon weighted particles, and inert materials and strict compliance with inspection disturbance of aquatic life the license - Mining activity of construction - Terrace working on quarries, backfill on contractor (if being undertaken) the worked areas and harmonization with found technically sound and the landscape compliant with the license - Working out of gravel outside water flow, conditions arrangement with separating ridges and without putting equipment into water flow

Generation of - Pollution of soil, surface - Temporary storage of construction waste - Construction waste found at the No specific extra Meghri construction waste water and ground water, in especially allocated areas; work site piled up in designated cost: common Municipality - Accidents at the - Timely disposal of wastes to the formally locations responsibility of construction site due to designated locations - No excessive amount of works contractor Construction scattered fragments of - Hand-over of larger amounts of hazardous construction waste stored on site contractor construction materials and wastes to the companies having license for - Documents present on the debris, decontamination and placement of handover of larger amounts of - Deterioration of esthetic hazardous materials. hazardous waste to companies appearance of the licensed for its disposal construction site and its surroundings Production of Pollution of soil and water - Placement of waste collection containers at - Waste collection containers No specific extra Meghri household waste with domestic waste the construction site and construction base found at the construction site cost: common Municipality (if any) - No pollution of the construction responsibility of - Agreement with Meghri Municipality on site with household waste works contractor Construction regular disposal of domestic wastes contractor Production of liquid - Flooding of the - Arrangement and maintenance of toilets in - Toilets provided at the No specific extra Construction wastes construction site and compliance with sanitation norms at the construction site and found in cost: common contractor complication of activities construction site and construction base (if good sanitary condition responsibility of - Pollution of surface and any) - No water logging of works contractor ground waters construction site

43 - Arrangement and regular cleaning of drainage system for storm water collection and drain - Arrangement of sedimentation pond for water used for domestic and machinery washing purposes

Operation of - Population disturbance - Obtaining of emission permit by the - Construction contractor holding 450 USD Construction asphalt-concrete near the construction site construction contractor and strict permit for operating asphalt- contractor plant - Atmospheric air and compliance with it concrete plant and found surface water pollution - Selection of a place for the plant that compliant with its conditions provides minimal disturbance of population - Adequate placement of a plant, with noise, dust and exhaust which is least harmful for the - Arrangement of sedimentation pond for environment and disturbing for waste water from the plant population - Presence of sedimentation pool for a plant runoff. - No complaints from nearby residents Construction site re- Loss of aesthetical value of - Dismantlement of construction base (if - No remnants of a work camp 4000 USD Construction cultivation and the landscape due to any) and temporary access roads to the site left behind after demobilization Contractor landscaping construction of the Medical (if any) and asphalt-concrete plant and of contractor Center harmonization of the areas with the - Temporary access roads landscape harmonized with landscape and - Final cleaning of the construction site and enabling conditions provided for permanent access roads and landscaping- natural regeneration of greening of the area vegetation - Construction site ladnscaped and greened

44 Labor safety Traumatism and accidents - Provision of construction workers with - Construction workers found No specific extra Construction at work site working clothes and PPE wearing uniform clothes and cost: common Contractor - Strict compliance with the rules of adequate protective gear during responsibility of construction equipment operation and usage inspections works contractor of PPE - No violations of equipment operation and use instructions registered during inspections Operation Phase Waste water Pollution of ground water - Water samples collection and testing with Water released to neighboring 60 USD Medical Center discharge after and neighboring surface strict compliance with technical guidelines. relief after treatment in WWTP per 1000 m3 treatment water bodies - Existence of emergency plan for cases of meeting the following revealing of incompliance with waste water parameters:

parameters and immediate implementation BOD5 -15mg/l 02

of the plan COD - 30 mg/l 02 Total Nitrogen - 3.5 mg/l Total phosphorus - 2 mg/l Mismanagement of - Raw sudge disposed at the - Control over the physical and chemical - No release of hazardous raw To be included in Medical Center sludge from waste municipal landfill or parameters of sludge prior to its disposal or sludge from the hosital site. the municipal water treatment unit handed out to farmers for release to farmers - No accumulation of budget for local Meghri fertilization of fields; - Logistaical arrangements in place for excessivevolumes of sludge on road maintenance Municipality - Accumulation of periodic out-transportation of dryied sludge. the hospital site excessive amounts of - Control over the condition of sludge - No incidence of leaking from sludge at the MC site due to drying platform to prevent leakage of its the sludge drying platform. failure of timely out- bottom or roof transporting; - Leakage of runall from sludge drying platform to the dround water and nearly serfuace water bodies

45 Emergency cut-offs Disrpution of the hospital - Back-up arrangements in place for Smooth operation of the Medical To be included in Medical Center in the utility service operation causing nuisance ensuring permanent supply of electric Center the WWTP provision (electric to the staff and patients power, hot water and healing to the Medical operation and power, water, gas) Center maintenance and fire incidence - Fire emergency preparadness of the budget hospital staff and existence of water stock for fire-fighting

46 Environmental Monitoring Plan

Activity What Where How When Why Who

Construction phase

Provision of construction Purchase of construction In the provider’s office or Verification of During conclusion Provide technical HPIU materials materials from the licensed warehouse documents of supply contracts order of facility and provider its safety for human health Transportation of - Technical condition of - Construction site Inspection of roads Undeclared - Limit pollution of HPIU, construction materials and vehicles and machinery - Routs of transportation adjacent to the inspections during soil and air from Inspection waste - Confinement and protection of of construction materials construction object work hours and emissions; Police Limit nuisance to truck loads with lining and wastes in the direction of beyond - Respect of the established local Movement of construction the movement rout hours and routes of machinery - Communities from transportation noise and vibration;

- Minimize traffic disruption. Maintenance of - Washing of cars and Construction site and Inspection of During operation - Avoid pollution of HPIU construction equipment construction equipment outside construction base adjacent activities of equipment water and soil with the construction site or on to it (if any) oil products due to maximum distance from the operation of river equipment - Refueling or lubrication of - Timely localize and construction equipment and decrease expected outside the construction site or at damage in case of the predetermined arranged fire point. - Technical order of the construction equipment maintenance point

47  solid impenetrable floor or adsorbent (sand fine gravel, membrane) cover  enough area and impenetrable barriers around fuel containers  basic fire extinguishing means

Earth works - Topsoil removal and temporary Construction site Inspection of During earth works - Limit loss of HPIU storage at a separate place at the activities vegetations due to State Agency beginning of works (to dispose ground piling and for Historical to landfill in case of pollution minimization of and Cultural and for re-cultivation of the land pollution of surface Monuments if it is good) water reservoirs with Protection - Temporary storage of particles excavated soil at determined and - Limit pollution with allowed places in compliance contaminated soil of with ground piling parameters. surface and ground - Backfilling of the excavated waters material as needed and disposal - Avoid loss of of the excess mass to the places, cultural heritage approved in writing. - Immediate termination of activities in case of unexpected archaeological findings and providing of full information to the Agency of cultural heritage

Extraction of inert - Purchase of inert materials Quarries of inert materials Inspection of During excavation - Limit slope erosion HPIU material from the existing suppliers, if documents and reclamation at and landscape Ministry of there is such opportunity Inspection of quarries damage Nature - Obtaining of the license for activities Protection 48 production of inert materials and - Limit erosion of strict compliance with the river banks, pollution license of water flow with - Terracing of quarries, weighted particles backfilling of exploited areas and disturbance of and harmonization with the aquatic life landscape - Excavating gravel outside water flow, arrangement of separating ridges between water flow and excavation area, banning entrance of watery by vehicles and machinery Generation of Temporary storage of Construction site; Inspection of Periodically during - Prevent pollution of HPIU construction waste construction waste in especially Waste disposal site activities construction and soil, surface water allocated areas; upon its and ground water, Meghri - timely disposal of wastes to the completion - Avoid accidents at Municipality formally designated locations the construction site

due to scattered fragments of construction materials and debris, - Retain esthetic appearance of the construction site and its surroundings Production of domestic - Placement of waste collection Construction site and Visual observation Total period of Prevent pollution of HPIU wastes containers at the construction construction base (if any) construction soil and water with Meghri site and construction base (if domestic waste Municipality any) - Agreement with Mtskheta Municipality on regular disposal of domestic wastes

49 Production of liquid - Arrangement and maintenance Construction site and Visual observation Total period of - Prevent flooding of HPIU wastes of toilets in compliance with construction base (if any) construction construction site and sanitation norms at the disruption of works construction site and In case of waste due to water logging construction base (if any) precipitations - Reduce pollution of - Arrangement and regular surface and ground cleaning of drainage system for waters rain water collection and drain - Arrangement of sedimentation pond for water used for domestic and machinery washing purposes

Operation of asphalt- - Obtaining of emission permit Construction site and Inspection of Total period of - Limit population HPIU, concrete plant by the construction contractor construction base (if any) documents plant operation disturbance near the Ministry of and strict compliance with it construction site Nature - Selection of a place for the Inspection of - Limit atmospheric Protection plant that provides minimal activities air and surface water disturbance of population with pollution noise, dust and exhaust - Arrangement of sedimentation pond for waste water from the plant

Construction site re- - Dismantlement of construction Construction site, Inspection of Final period of Reduce loss of HPIU, cultivation and base (if any) and temporary construction base and activities construction aesthetical value of Meghri landscaping access roads to the site (if any) temporary access roads the area Municipality and asphalt-concrete plant and (if any) harmonization of the areas with the landscape - Final cleaning of the construction site and permanent access roads and landscaping- greening of the area

50 Workers’ health and - Provision of constructors with Construction site Inspection of Total period of Reduce probability of HPIU safety working clothes and PPE activities works traumas and - Strict compliance with the rules accidents to of construction equipment constructors operation and usage of PPE Operation Phase Water discharge after Compliance of treated water Sanitary Laboratory of - Collection and Total period of Prevent river water Medical purification of sewage with the following parameters: Megrhi epidemiological testing of water operation of the pollution Center, mass BOD5 -15mg/l 02 service samples with strict facility

COD - 30 mg/l 02 compliance with Syunik Total Nitrogen – 3.5 mg/l technical guidelines. department of Total phosphorus - 2 mg/l - Existence of State emergency plan for Environmental cases of revealing of Inspectorate incompliance with waste water parameters and immediate implementation of the plan Accumulation of sludge - Sludge drying platform Medical Center premises Inspection of the Total period of - Avoid disturbance Medical provided and maintaned in good sludge drying operation of the of the staff and Center, tehnical condition preveting platform facility patients of the leakage of its roof and bottom Medical Center Meghri - Logistical arrangements in - Prevent anti- Municipality place for out-transporting of sanitary conditions sludge and spread of - Control established over the infection physical and chemical - Prevent pollution of parameters of sludge prior to its ground water and out-transporting surface water bodies with runoff from the sludge

51 Emergency situations at - Existence of back-up Medical Center premises Inspection Total period of Smooth operation of Medical the Medical Center arrangements for sustaining operation of the the Medical Center, Center electric power supply, water Medical Center safety of its staff and supply, and heating in case of patients Syunik external emergency cut-offs department of - Water stocked for fire-fighting State Environmental Inspectorate

52 Annex 3 Calculation of Emissions, Water Use and Water Discharge

Impact on the environment during construction works a) Dust emissions during drilling-loading operations Q1 = (P1 x P2 x P3 x P4 x P5 x G x 106 x B x P6) / 3600 t/hour (formula 1), where P1 - faction share of the dust in priming, 0.05 P2 - 0-50 micron size particles share in the spread of dust aerosol, 0.03 P3 - coefficient, which takes into account the average wind speed at the construction equipment work area, 1.0 P4 - coefficient, which takes into account the content of moisture in the substance, 0.6 P5 - coefficient, which takes into account the size of the substance , 0.2 P6 - coefficient, which takes into account the site conditions, 1.0 B - coefficient, which takes into account the height of material unloading , 0.5 G – amount of reprocessed priming, taking into account the priming, vegetated soil and dismantled asphalt: 6793.65 m3 or 18003.0t. Soil construction works will be carried out in 2 months: 2 months x 30 days / month x 10 hours / day = 600 hours/construction. 18003.0 t : 600 hours = 30.0 tons / hour. 6 Q1 = (0.05 x 0.03 x 1.0 x 0.6 x 0.2 x 30.0 x 10 x 0.5 x 1.0)/3600 = 0.75g/sec. Total emissions after soil works completion will make: 0.75 g/sec. x 600 hours x 3600 seconds/hour: 1000000 g/t = 1.62 t/construction. b) Diesel fuel combustion outcomes Diesel related fuel emissions are calculated on the basis of "Determination of hazardous substances amounts emitted from auto transportation into the atmosphere” methodical instruction. According to the mentioned methodology the specific emissions of heavy auto transportation and mechanical equipment are presented below in Table 1. Specific emissions (g/kg fuel)

Fuel Type Name of substance NOx CH VOC CO N2O CO2 PM Diesel fuel 42.3 0.243 8.16 36.4 0.122 3138 4.3

Taking into account that newly purchased equipment will be used, age-related parameters of park are not applied. In total 5 pieces of technical units will be used in the process of construction works (2 units of trucks, 1 unit - excavator, 1 unit - bulldozer and 1 – lifting crane), which operate on diesel fuel. Diesel fuel consumption during construction works (16 months) will make: 12.0 t, the daily average 0.03t/day.

Sulfuric anhydride

Sulfuric anhydride (SO2) emissions are calculated based on the approach that the entire sulfur contained in fuel fully turns into SO2. In this case CORINAIR inventory system formula is applied: ESO2=2Σksb, where ks- the average content of sulfur in the fuel: 0,002t/y b- is the fuel consumption: 12,000t/constr. SO2 = 2 x 12.0 x 0.002 = 0.048 t/constr. or 0,004g/sec.

53 c) Welding works The welding works to be carried out during 330 day-period in total 2640 hours. 16 kg of electrode demand is estimated for average daily rate.

Welding aerosol: 14.4g/kg x 16kg/day = 230.4g/day, 0,008g/sec., 0,076t/constr. hours Manganese oxides: 1.87g/kg x 16kg/day = 29.92g/day, 0,001g/sec., 0.01t/constr. Hours d) Emissions as a result of bitumen works

Evaporation of solvents used for dissolving the bitumen during bitumen laying takes place. Calculation was made according to Corinair (7) methodology (SNAP CODE 040611). Volatile organic compounds (VOC) GVOC=Vasfx K1 x K2, where GVOC - emissions of organic dissolvent during the period of construction, t/constr. 2 3 Vasf - volume of all types of bitumen: 1612.6 m x 0.002m = 3.23m , taking into account the specific weight of technical bitumen: 1.01 - 1.06 m3/t, the amount will reach 3.3t K1- 0.25 K2-, 0.05; GVOC= 3.3x0.25x0.05=0.041t/constr. time or dividing to the entire period of bitumen laying works: 0.041 x 106: 25: 8: 3600 = 0.057g/sec. e) Asphalt laying

Evaporation of solvents used for dissolving the bitumen and asphalt masses after filling the asphalt cover during asphalt laying takes place. Calculation was made according to Corinair (7) methodology (SNAP CODE 040611).

G=Vasf x K1 x K2, where G - emission of organic dissolvent during the period of construction, t/constr. 3 Vasf - volume of all types of asphalt, 109 m , and taking into account the specific weight of technical bitumen: 1.2m3/t, the volume will make: 131.0t K1- ratio of dissolvent content: 0.1 K2- the share of hydrocarbon emissions according to dissolvent volume: 0.05; G = 131 x 0.1 x 0.05 = 0.655t/constr. time or dividing to the entire period of asphalt laying works: 0.655 x 106: 241: 30: 3600 = 0.25g/sec.

Summarizes of the calculations results according to the types of activities and separate substances/materials are described below in Table 3.

Nitrogen oxides and hydrocarbons are combined in transportation emissions, taking into account the rapid transformation of nitrogen oxide into the atmosphere, as well as the commonness of hydrocarbons and VOC characteristics. 1.2. Center’s operational phase Calculated emissions of hazardous substances

Boiler stations to be installed at the Meghri Medical Center shall be certified in accordance with EN 257 and EN676 European Union standards that provide low level of hazardous substances emissions (Low NOx). They are expected to generate nitrogen oxides emissions which are ≤ 97 mg/kW hour in case of natural gas and ≤ 180 mg/kW hour for liquid fuel operations.

54 The maximum thermal demand of the Medical Center makes 470 kW hour.

Emission estimates for natural gas The nitrogen oxide emissions in case of maximum demand will make: GNO2 = GNO2 = 97 mg/kW x 470 kW= 45590 mg or 45.59 g/h (0.013 g/sec.) Emission source is the one general smoke pipe with 8m of height and having 0.25m internal diameter. The annual emissions are calculated using the annual maximum thermal demand. The annual emissions of nitrogen dioxide generated as a result of boiler-house operation are calculated according to the required quantity of natural gas. To satisfy the heating and hot water supply demand estimated volume of natural gas makes 46630 nm3, and due to solar heater installation the natural reduction will make 1795 nm3. 46630 - 1795 = 44835 The natural gas calorific value was accepted to be 9.2 kW h/m3. 9 GNO2 = 44835 x 9.2 x 97: 10 = 0.04 t/year.

Emission estimates for diesel fuel

During emergency disconnections of natural gas the burners are automatically switched on to diesel fuel supply system. The nitrogen oxide emissions in case of maximum demand will make: 180 mg/kW x 470 mg = 84600 kW or 84.6 g/h (0.0235 g/sec.) The annual emissions are not calculated as the diesel fuel is only used during natural gas emergency disconnections, which may not have long-term nature.

Water use and water discharge calculations 2.1 Construction phase Water usage Construction platforms Taking into account that at the same time the construction works are carried out in one part of construction area, which calculated surface makes about 2600 m2, the watering calculation was carried out for that size of the area. M1 = S1 x K1 x T, where 2 S1 – surface of watered area 2600 m , 2 3 K1 - 1 m daily watering norm, 0,003 m ; T – construction period by days, during which watering is to be carried out, 240 3 3 M1 = 2600 x 0.003 x 240 = 1872.0 m / constr. hours or 7.8 m /day

Communal-domestic use water demand calculation for administrative employees and workers (including drivers)

The water consumption of employees and workers (including drivers) for drinking and domestic needs is calculated as follows: Wcubic t = (n x N x + n1 x N1) T1,where n - number of engineer technical employees: 4 people N- engineer technical personnel water consumption normative: 0,016 m3day/person T1 - number of working days: 528 days n1- number of workers (including drivers): 17 people 3 N1 - workers water consumption normative: 0,025 m day/person

55 3 Wcubic t = (4 x 0.016 + 17 x 0.025) x 528 = 258.2 m /constr. hour Average daily 0.5 m3/day

Testing of water pipes and washing with chlorine water will make: 6.0 m3

The total water use during the construction phase will make:

1872.0 + 258.2 + 6.0 = 2136.2 m3/constr. hour or 8.3 m3/day

Water discharge Water volume used for watering and pipes washing is classified to irredeemable water use and losses. The wastewaters volumes originating due to drinking water use make:

Wwater discharge = Wcubic t– (Wcubic t x K), where K – coefficient of losses, 0.015 3 3 Wwater discharge = 258.2 – 258.2 x 0.015 = 254.3 m /constr. hour, or 0.49 m /day.

2.2. Operational phase Water usage Drinking and domestic water consumption demand for service and medical personel

Wcubic t = n x N x T1, where n – number of administrative and service personnel: 100 people N–water consumption normative: 0.016 m3 day/person T1 - number of working days: 260 days 3 3 Wcubic t = 100 x 0.016 x 260 = 416.0 m /year or 1.6 m /day

Calculation of laboratories water demand

Chemical and biological laboratories are envisaged to be built. L = (k1 x n1 + k2 x n2)x T, where 3 k1 – normative of chemical laboratory water consumption: 0.48 m /day n1 – number of laboratory employees: 4 people 3 k2 – normative of biological laboratory water consumption: 0.31 m /day n2 – number of laboratories: 1 person T – number of working days: 260 days L = (0.48 x 4 + 0.31 x 4) x 260 = 821.6 m3/year or 3.16 m3/day

Calculation of kitchen water consumption demand

Wcubic = 0.016 x (N1 x T1 x m1 + N1 x T1 x m1) 0.016 – normative of water consumption for preparing one kind of meal N1 – maximum number of patients: 45 T1 – number of calendar working days: 365 m1 – daily consumption of a meal for one client: 3 N2- medical personnel: 100 T2 – number of calendar working days: 260 m2 – daily consumption of a meal for one client: 1 3 Wcubic = 0.016 x (45 x 3 x 365 + 100 x 1 x 260) = 1204.4 m /year

56 Calculation of hospital beds water consumption demand

Wb.= 0.2 x N x T 0.2 – normative of water consumption for one hospital bed N – number of hospital beds: 45 T – number of calendar working days: 365 3 Wb. = 0.2 x 45 x 365 = 3285.0 m /year

Calculation of laundry house water consumption demand

Number of dry linen: 8 kg/month water use norm: 0,075 m3 of water/kg number of working days (months): 12 months number of hospital beds: 45 The laundry house water use will be: 8 x 0.075 x 12x 45 = 324.0 m 3/year Calculation of irrigation water consumption demand for green areas

W irrigation = 0.003 x S x k x T S - area of land under irrigation: 1200 k - the number of watering days: 1 T - the number of watering days during the year: 150 3 W irrigation = 0.003 x 1200 x 1 x 150 = 540.0 m /year

Calculation of water consumption demand for wet cleaning of floors

W pcs. = 0.0005 x S x k x T S - surface area of floors: 2400 m2 k - the number of floors washed in a single day: 2 T - the number of working days during the year: 365 3 W pcs. = 0.0005 x 2400 x 2 x 365 = 876.0 m /year Average daily: 10:15 m3/day.

Water discharge

The water use for washing floors and irrigation is classified to irredeemable water usage. The drinking, domestic, cafeteria, laundry house and laboratories used water discharge utilized by service and medical personnel and patients is calculated by the following formula:

WΣ = WΣ - AWL where AWL is the average water loss (in percentage -2%) 3 AWLl = WΣ x 0.02 = (416.0 + 821.6 + 1204.4 + 3285.0 + 324.0) x 0.02 = 121.0 m /year 3 W w.d. Σ. = 6051.0 - 121.0 = 5930.0 m /year. Average daily: 16.25 m 3/day. Total water use will make: • 7467.0 m3/year. • The daily average, 20.5 m3/day; Total wastewater outflow will be: • 5930.0 m3/year. • The average daily: 16.25 m3/day.

57 Annex 4. Calculation of Economic Damage

1. Atmospheric air The economic damage for each emission source is estimated by Formula 1: A = Ec Ti Σ Hi Ai, where I – impact expressed in AMD, Ec - the coefficient of characteristic of the environment’s polluting source (active contamination zone), in accordance with the procedure referred to in Table 9 for the fruit orchards areas is set to be 1.0. Ti - transport index, is a constant and is chosen based on the principle of promoting the environmental protection and according to the given procedure Ti = 1000. Hi - the value expressing the i-th substance (dust type) comparative harmfulness, for inorganic dust is 10.0, carbon oxide: 1, hydrocarbons: 3.16, nitrogen dioxide: 12.5, solid particles: 200, sulfuric anhydride: 16.5, welding aerosol: 41.0, manganese oxides: 705. Ai - is the given coefficient of (i-th) substance emission amount, coefficient is determined by Formula 2: Ai = c (3 Aai - 2 MACi), Aai > MACi (2), where MACi – is the i-th substance annual MAC amount in tons, Aai - is the i substance actual annual emissions in tons, c = 1 for the immovable sources (taking into account that the construction machinery works at the same platform, and the same coefficient is applied). Considering that the spreading calculations of hazardous substances emissions into the atmosphere showed that the expected ground base concentrations are in the range of permissible norms, Ai = Aai The impact is not assessed for the substances which normative volume concentration is not defined by state standard.

a) Construction works: I = Ec Ti ∑ HiAi = 1.0 x 1000 x {10 x 6.62 + 1 x 0.44 + 3.16 x 0.799 + 12.5 x 0.5 + 200 x 0.052 + 16.5 x 0.048 + 41.5 x 0.076 + 705 x 0.01} = 96810.8 AMD/per annum. b) Operational phase

For the operational phase the Oc is defined to be 10.0, as health zone: I = Ec Ti ∑ HiAi= 10.0 x 1000 x 12.5 x 0.04 = 5000 AMD/per annum.

2. Soil The impact is calculated by the following formula:

I = Eal + Val + Eea, where I - impact, Eal - necessary expenditures required to recover the affected land area to preliminary (normative) condition (requirements for recovery) Val - the affected land (inventory) value, Eea - expenditures connected with examination of impact consequences and analysis: a) The calculated surface of affected land area makes 3000 m2 The required expenditures necessary to bring to preliminary (normative) condition are calcutaed based upon the value of necessary measures. Such measures can be considered as covering the soil cover of the taken out vegetated layer and smoothing. The average cost of these works at different areas makes: 200 - 300 AMD/m2. Taking the value of 250 will receive: 3000 m2 x 250 AMD/m2 = 750000 AMD. b) A is calculated by the following formula:

58 A = S x R x T/365 x Ce x Cp, where A- is the value of infringed (affected) land (area) starting from the period of infringements (affecting) till the land (area) recovery to preliminary (normative) condition (recovery of conditions), S- affected land (area) surface: in m2, that is decided based on actual examinations, in the given case 3000 m2, R - base tariff of land area rent, that is calcuated - for non agricultural (other significance) lands in accordance with the RA government N 1746-N decree as of December 24, 2003 “In accordance with the RA residential lands cadastre assessment procedure, the given land cadastre price.” According to the mentioned procedure the lands cadastre price is calculated by the following formula: CPland = Pbase x Sland x Zf , where CPland - estimated land area cadastre price, expressed in AMD, Pbase - base price of residential lands one square meter, expressed in AMD, according to 1746-N decree makes 60000AMD/m2 Sland – surface of estimated land, expressed in square meters, 3000 Zf - residential lands localization (location area) zoning factor, for Syunik marz Meghri community lands: 0.0088 (1746-N, annex 2). 60000AMD/m2 x 3000 m2 x 0.0088 = 1584000 AMD. R = 1584000 : 3000 = 528.0 AMD/m2 T - the time period required to recover the affected land area to preliminary (normative) condition (requirements for recovery), expressed in days: 10 days 365 – days as coefficient for a year, Ce – coefficient considering the environmental value of the land (area), that is calcuated based upon the 21st point 1.4 (other lands) of the given procedure, Cp - coefficient of installed (accumulated, left unattended) waste harmfulness (poisoneous), which is calculated according to the 22nd point of the given procedure, 1.0 I = 3000 m2 x 528.0 AMD/m2 x 10/365 x 1.4 x 1.0 = 60756.0 AMD c) Expenditures connected with the impact study and analysis are determined by the value of similar works carried out by specialized organization and will make 80000 drams. Thus, the economic damage caused to the land resources will make: I= 750000 drams + 1584000 drams + 80000 drams = 2414000 drams.

59 Annex 5. Waste Generation Expected Types of Waste from the Meghri Medical Center

Codes Types of Waste Aggregate Status Origin and Physical Form 97010100 01 05 3 Medical waste risky for human health (infectious) Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 97010200 01 05 3 Disinfection waste Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 97010400 01 05 3 Medical waste, which are risky in terms of injuries or Solid Health care (wide profile, specialized hospitals, maternity hospitals, infections polyclinics)

97010800 13 05 3 Used single-use syringes Finished goods that have lost Health care (wide profile, specialized hospitals, maternity hospitals, their consumer properties polyclinics) 9701030 01 05 4 Human body and internal organs Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 9701050 01 99 4 Sharp objects (lancet, scalpel) Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 9701060 01 05 4 Medical waste formed due to health care services Solid Health care (wide profile, specialized hospitals, maternity hospitals, provision (diagnostics, prevention, treatment and child polyclinics) delivery) 9701070 01 05 4 Broken or used medical needles Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 9701080 13 00 4 Medical devices and instruments that do not meet certain Finished goods that have lost Health care (wide profile, specialized hospitals, maternity hospitals, requirements, for example, thermometers, diagnostic their consumer properties polyclinics) instruments, syringes 9701090 01 05 4 Other wastes which collection and destruction is carried Solid Health care (wide profile, specialized hospitals, maternity hospitals, out in accordance with specific requirements, in order to polyclinics) prevent the spread of infections

9701190 01 00 4 Other wastes which collection and destruction is not Solid Health care (wide profile, specialized hospitals, maternity hospitals, carried out in accordance with specific requirements in polyclinics) order to prevent the appearance of infections

9701390 01 00 4 Other medical waste for protection of human health Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics)

60 Annex 6. Minutes of Public Consultation Meeting

PUBLIC CONSULTATION MEETING IN MEGHRI CITY ON ENVIRONMENTAL ISSUES OF CONSTRUCTION OF MEGHRI REGIONAL MEDICAL CENTER

Date: November 6. 2012

Place of meeting: Meghri city Policlinic

List of participants:

1. Davit Melik-Nubaryan HPIU coordinator 2. M. Zakaryan Mayor, Agarak Community 3. A. Hovhannisyan Mayor, Meghri Community 4. Tsaghik Vardanyan Director, Meghri regional MC 5. M. Ohanyan Administration member, Meghri community 6. S. Hakobyan Director, Meghri Employment Center 7. S. Harutyunyan Head, Meghri Women’s Resource Center, NGO 8. N. Khachatryan Head, Health and Wellfare, NGO 9. T. Hovhannisyan Head, Agarak kindergarden 10. A. Mirzoyan HR Manager, Agarak Mining Factory 11. S. Mikaelyan Head, Agarak Mining Factory trade union 12. A. Beklaryan Head, Vardanidzor Community 13. H. Ohanyan Head, Shvanidzor Community 14. Other health care providers and activists

Summary

Public hearings in Meghri city on Environmental issues of construction of Meghri MC took place on November 2012. The Public Hearings were carried out with participation of HPIU coordinator of “Hospital System Optimization” component Davit Melik-Nubaryan, marz authorities: Mayor of Meghri city, Syunik representatives of marz Government Health and Social Defense Department, as well as Director of Meghri MC, representatives of NGOs, journalists, other health care providers and activists from the region.

HPIU Coordinator Davit Melik-Nubaryan presented the Meghri regional Center construction Project. He presented also the report on Environmental Management Plan on Construction activities of Meghri MC, where the environmental risks and possible impacts were presented. After the presentation several questions were asked by the participants. - The Mayor of Meghri city was interested how the site for location of the new MC had been selected.

61 Mr. Melik-Nubaryan explained that the location of the Meghri MC was suggested as a result of studies performed by specialists and two main criteria were taken into account while selecting the site area. a. the selected area should be equally accessible both for population of Agarak and Meghri sub-regions b. the selected area should meet all the requirements for hospital location. In addition, the Mayor of the Agarak city supported the choice of the location area.

- The question about future employment of the staff was raised by the Director of Meghri employment Center and one of the Meghri MC staff members.

Mr. Melik - Nubaryan answered that the construction activities were unfortunately delayed due to technical problems: the tender for the selection of Constructor Company for the construction of Meghri regional MC was announced on August 24, 2012 and bid opening took place on 5th of October. But after evaluation the results, there was no winner announced, because of high Quotations (up to 60%). New International tender for construction civil works of Meghri MC was announced on April 11, 2013. The opening of bidding documents is planned on May 23, 2013. Based on this experience while announcing the future tenders more companies will be involved in order to avoid such kind of problems.

- The Director of Meghri Regional MC emphasized that the construction activities must meet the requirements of environmental safeguards.

Mr. Melik - Nubaryan assured that the environmental questions are of great importance and very strong monitoring of environmental impacts will be carried out through whole period of construction activities of the MC. The public hearings lasted for about 2 hours.

62 The scanned copies of signatures of participants:

63 Annex 7. Certificate of Absence of the Known Historical and Archeological Monuments from the Project Site

Dear Mr. Dumanyan

I inform you that there are not any Historical and Cultural Monuments on the construction site area of the Meghri Medical Center

With best regards,

Mayor of Meghri S.Hayrapetyan

Annex 8. Land Certificate Issued for the Allocated Site