E2504 v2 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized
Submitted to: The Ministry of Public Health and Population, Yemen Environmental and Social Impact Assessment (ESIA)
EcoConServ Environmental Solutions JET for Engineering and Trading Health and Population Project
Public Disclosure Authorized 10 El Kamel Mohamed St., Zamalek, Riyad (Hayil) Street, Al-Ghail Building 1st Cairo, Egypt 11211 Floor, Suite no. 1, Sana’a, Tel: + 20 2 27359078 – 2736 4818 Republic of Yemen, P.O. Box 2379 Final Report Fax: + 20 2 2736 5397 Tel.: + 967 1 212 567 E-mail: [email protected] Fax: + 967 1 211 097 URL: http://www.ecoconserv.com E-mail: [email protected] July 2010 URL: http://www.geocities.com/jetyemen Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
TABLE OF CONTENTS
LIST OF TABLES ...... 5 LIST OF FIGURES...... 5
Executive Summary ...... 8
LIST OF ACRONYMS AND ABBREVIATIONS...... 12
1. Introduction ...... 14 −˜ł− Background ...... 14 1.2 Health and Population Project˜(HPP)...... 14 1.2.1 Project Objective...... 14 1.2.2 Objectives of the Environmental and Social Impact Assessment (ESIA) ...... 14 1.3 ESIA Methodology ...... 15 1.3.1 Phase One: Description of the Current Situation ...... 15 1.3.2 Phase Two: Analyzing Results and Preparing the draft ESIA...... 16 1.3.3 Phase Three: Presenting Results and Consultation with Stakeholders ...... 16 1.3.4 Phase Four: Preparing the Final ESIA and Disclose the Report...... 16 1.4 The ESIA Challenges and Methodology Strengths...... 17
2 Legislative Framework...... 19 2.1 Laws Related to the Environmental Impact Assessment ...... 19 2.1.1 Environmental Protection Law No. 26 of 1995 ...... 19 2.1.2 Law 40/1999, the Law of Hygiene...... 19 2.1.3 Law 60/1999 for Medical and Health Facilities...... 20 2.1.4 Law 39/1999 about Public Hygiene...... 22 2.1.4.1 Article (19) Concerning Healthcare Waste ...... 22 2.2 Laws Related to Social Impact Assessment...... 24 2.2.1 Yemeni Constitution ...... 24 2.2.2 Local Administration Law (number 4/2002) ...... 24 2.2.3 Public Health Law (number 4/2009)...... 24 2.2.4 Presidential Decree (number 76/2004)...... 25 2.3 International Regulations Related to the Project...... 25 2.3.1 The Convention on the Rights of Children (CRC)...... 25 2.4 World Bank Safeguard Policies ...... 26 2.4.1 Environmental Assessment Policy (OP 4.1) ...... 26 2.4.2˜Disclosure Policy (OP 17.50)...... 26
3. Health and Population Project (HPP)...... 27 3.1 Project Objective...... 27 3.2. Project Description...... 27
4. Description of the Environment and Socio-economic Conditions...... 33 4.1. Description of the Environment ...... 33 Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
4.1.1 Location...... 33 4.1.2 Geological and Hydrological Characteristics of Yemen...... 34 4.1.2.1 Terrain ...... 34 4.1.2.2 Soil ...... 37 4.1.2.3 Climate ...... 38 4.1.3 Ecological Classification of the Study Area ...... 39 4.1.3.1 Environmental Characteristics of the Study Area...... 39 4.1.3.2 Elements of Biodiversity in the Region ...... 41 4.1.3.3 Risks and Threats Facing the Region...... 43 4.1.4 Environmental Background based on the Findings of the Field Study...... 44 4.2 Socio-economic Background ...... 50 4.2.1 General Background Information on the Socio-economic Conditions in Yemen ... 50 4.2.2 Economic Characteristics...... 53 4.2.2.1 Poverty Level in Targeted Governorates: ...... 54 4.2.3 Education...... 55 4.2.4 Gender Issues ...... 57 4.2.4.1 Economic Participation among Women...... 58 4.2.4.2 Women and Education ...... 59 4.2.5 Health Indicators Related to the Project...... 60 4.2.6 The Main Causes of MNCH Problems ...... 65 4.2.7 Organizational Backgrounds Related to the Project ...... 72 4.2.7.1 Governmental Sector...... 72 4.2.7.2 Other Bodies Concerned with MNCH in the Targeted Governorates ...... 79
5. Analysis of the Project Environmental and Social Impacts ...... 84 5.1 Expected Environmental Impacts...... 85 5.1.1 Expected Environmental Impacts during Preparation/Pre-implementation Phase .. 85 5.1.2 Expected Environmental Impacts during Operation Phase...... 85 5.1.2.1 Impacts Related to Improper Handling and Storage of Chemicals and Drugs ..... 85 5.1. 2.2 Inappropriate Disposal of HCW Generated during Outreach Activities ...... 87 5.1.2.3 Mismanagement of Increased Quantities of Municipal Solid Waste Generated by Healthcare Facilities...... 87 5.1.2.4 Use of Poorly Maintained Electric Generators ...... 88 5.2 Expected Social Impacts ...... 91 5.2.1 Expected Social Impacts during Preparation/Pre-implementation Phase ...... 91 5.2.1.1 Creating Temporary Economic Opportunities ...... 91 5.2. Expected Social Impacts during Operation Phase...... 91 5.2.2.1 Job Opportunities for Women in the Field of Community Health...... 91 5.2.2.2 Improving Women’s Access to Pregnant Women’s Health Services ...... 93 5.2.2.3 Improving Child Health and Safety at Remote and Disadvantaged Areas ...... 93 5.2.2.4 Enhanced Level of Trust between Beneficiaries and Government Agencies ...... 94 5.2.2.5 Building the Capacities of Human Resources...... 95 5.2.2.6 Raising Community Awareness...... 95 5.2.2.7 Increasing Women’s Sense of Security ...... 96 5.2.2.8 Improving the Process of Monitoring Changes and Observing Indicators ...... 96
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
6. Project Alternatives...... 99 6.1 “No Project” Alternative ...... 99 6. 2 Alternatives during Operation Phase...... 99 6.2.1 Alternatives to Project Management...... 99
7. Environmental and Social Management Plan (ESMP) ...... 101 7.1 Environmental Management Plan during Operation Phase ...... 101 7.1.1 Handling Solid Waste...... 101 7.1.2 Controlling Emissions...... 102 7.1.3 Controlling Chemical Substances and Pharmaceuticals ...... 103 7.1.4 Handling Hazardous Waste...... 104 7.1.5 Controlling Noise ...... 109 7.1.6 Training, Awareness and Capacity Building Programs on the Safe Handling of Healthcare Waste...... 110 7.2 Recommendations for Tackling Social Risks and Maximizing Benefits...... 118 7.2.1 Awareness Raising Programs...... 118 7.2.1.1 Target Groups...... 118 7.2.1.2 Issues to be Included in the Awareness Raising Programs ...... 119 7.2.1.3 Awareness Raising Tools...... 119 7.2.1.4 Providers of Awareness Raising Campaign...... 119 7.2.2 Establishing a System for Participatory Monitoring and Evaluation (PM&E)...... 120 7.2.2.1 PM&E Tools ...... 121 7.2.2.2 Indicators of PM&E ...... 121 7.2.2. Implementing PM&E ...... 121 7.2.2.4 Timeframe for PM&E ...... 121 7.2.3 Strengthening the Fixed Facilities’ Human and Equipment Base...... 122 7.2.4 Development and Implementation of Coordinating Mechanisms between Relevant Stakeholders ...... 124 7.2.5 Mobilize Financial Resources to Ensure Project Sustainability...... 125 7.3 Organizational Structure for Implementing HPP...... 126 7.4 Environmental and Social Management Plan (ESMP) Budget ...... 129
8. Consultations with Stakeholders ...... 130 8.1 The Most Important Results from Meetings with Stakeholders during the Study of the Current Situation ...... 130 8.2 Important Findings from the Public Consultation...... 131
Conclusion...... 136
References ...... 137
Annex 1: List of Consulted Stakeholders...... 138 Annex 2: Guidelines for Healthcare Waste Management at Healthcare Centers and Facilities ...... 146 Annex 3: Documentation Package of the Public Consultation ...... 177
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
LIST OF TABLES Table 2.1 International Environmental Conventions Ratified by the Republic of Yemen 22 Table 4.1 Distribution of the Population According to Urban/Rural Distribution and Gender 51 Conditions - 2004 Census Table 4.2 Important Socio-economic and Population Indicators in Yemen 51
Table 4.3 Families and Gender Distribution in the Target Governorates 52 Table 4.4 Summary of the Topographic Conditions and Economic Activities in the Targeted 53 Governorates Table 4.5 Distribution of Employment (15 years and above) According to Economic Activity 54 in the Targeted Governorates Table 4.6 Average Enrollment to Education (ages 6-14) from 1991-2005 56
Table 4.7 School Enrollment Percentage (age 6-14) in the Targeted Governorates, 2004 56
Table 4.8 Educational Status of Yemen Population by Urban/ Rural Residence and Gender 57 Table 4.9 Percentage of Illiterate by Gender (more than 10 years) in the Targeted 60 Governorates, 2004 Table 4.10 Average Family Size in Targeted Governorates (1994 and 2004) 62
Table 4.11 Indicators Related to MNCH in Yemen 64 Table 4.12 The most important activities performed by donor bodies and NGO’s working in 82 the field of mother, infant and child health at targeted governorates Table 5.− Environmental Impacts during Project Operation and Suggested Mitigation 90 Measures Table 5.2 Impact Significance during Preparation/Pre-implementation Phase 91 Table 5.3 Impact Significance During Operation Phase 98 Table 7.1 Environmental Management Plan Matrix during Project Operation 112 Table 7.2 Environmental Monitoring Matrix during Project Operation 116 Table 7.3 List of Proposed Training Courses to Implement the Social Management Plan 123 Table 7.4 Proposed Budgets for the ESMP 129
LIST OF FIGURES
Fig 4.1 Map of Yemen 33 Fig 4.2 Map of Land Usage in Yemen 34 Fig 4.3 Important Valleys in Yemen 35 Fig 4.4 Geographic Regions in Yemen 36 Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Fig 4.5 The Amount of Rainfall in Yemen 38 Fig 4.6 Mountain Agricultural Terraces at the Area of Gebla, Ibb Governorate 40 Fig 4.7 Juniper Trees 41 Fig 4.8 Centaurothamnus plant 42 Fig 4.9 Carduelis Yemenensis bird 42 Fig 4.10 Turdus Menachensis bird 42 Fig 4.11 Ocelot 43 Fig 4.12 Spears (Running) Monkey 43 Fig 4.13One of the Qat Markets at 6am Showing Waste from the Previous Day 45 Fig 4.14 A Laboratory Basin in a Health Facility (Ka’tba hospital) 45 Fig 4.15 Used Syringes Thrown in Sewage in a Health Facility 45 Fig 4.16 Random Mixing of Wastes 46 Fig 4.17 Accessibility and Exposure of HCW to Children 47 Fig 4.18 A Primitive Incinerator at a Health Facility 48 Fig 4.19 Percentage of the Poor by Governorate 2005-2006 55 Fig 4.20 A Map of Orayeb Medical Center, Makiras District, Baydah Governorate 66 Fig 4.21 A Graph Representing the Percentage of Visitors to the Health Center from 66 Different Zones, Mohamed El Dora Hospital, Gahana, Sana’a Fig 4.22 Health Education Room, Mohamed El Dora hospital, Gahana, Sana’a 69 Fig 4.23 Health Education Room, Mohamed El Dora hospital, Gahana, Sana’a 69 Fig 4.24 Daily Consumption of Qat among the Sample of the Family Health Survey 70 Fig 4.25 and 4.26 National Center for Health and Population education studio where 72 awareness programs are prepared for broadcasting Fig 4.27 Organizational Chart of Yemen MoPHP 73 Fig 4.28 Different Targeted Levels of Governmental Health Facilities of MoPHP – Yemen 74 Fig 4.29 Operating Health Facilities in the Targeted Governorates – Health Analyzer 75 Program 2008 Fig 4.30 Number of Health Facilities with Referral Services in the Targeted Governorates - 76 Health Analyzer Program 2008 Fig 4.31 Service List of the Yemeni Family Care Association – Sana'a 82 Fig 4.32 Yemeni Family Care Association Building – Sana'a 82 Fig 5.1 Cracks in the Walls at Wa'lan Health Center 84 Fig 5.2 The Organizational Structure for CHV 92 Fig 7.1 Proposed Systems for the Safe Handling of Hazardous Waste at Health Facilities 105 Fig 7.2 Open Burning in a Barrel or Constructed Incinerator 108 Fig 7.3 Colored Bags for Distinguishing Waste 109 Fig 7.4 The Recommended Organizational Structure for HPP 128 Fig 8.1 Speakers at the Public Consultation 132 Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Fig 8.2 Presenting HPP Background and Description 132 Fig 8.3 Participant contribution during the open discussion session 132 Fig 8.4 Participant contribution during the open discussion session 132 Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Executive Summary
Yemen harbors a large diversity of geographic and topographic features varying from mountains to coastal areas, and from plains to deserts. The population in the Republic of Yemen is around 23,208,0001 where almost three quarters of the population live in rural areas. The Yemeni Republic faces many population-related challenges including high maternal and infant mortality rates.
The objective of the proposed Health and Population Project (HPP) is to improve the access to and utilization of a package of maternal, neonatal, and child health services in selected regions in Yemen by 2015. The proposed HPP is a project with a planned budget of around United States Dollars (USD) 58 million, of which the World Bank will be contributing an amount of USD 28 million. It aims, through its two components, at improving and supporting the provision of Maternal Neonatal and Child Health (MNCH), in addition to improving child health in target areas suffering from deteriorated health indicators due to accessibility challenges. This is to be achieved through a number of activities based mainly on outreach healthcare services and activities, in addition to other service packages targeting geographic areas that suffer from shortages in the provision of services. In addition to that, the HPP aims at improving referral services by supporting referral services facilities. The overall goal of the project is to assist the Government of Yemen (GoY) to accelerate the achievement of the Millennium Development Goals (MGDs), particularly MDG 4 and 5. This will be achieved through working to improve the MNCH in selected geographic areas that suffer from difficulties in accessing health facilities. The project is expected to meet its objectives by focusing on the delivery of outreach model as well as improving the primary health care fixed facilities in selected area. The project is built upon the existing outreach model and adapts an integrated approach that aims to deliver the outreach services to the areas that could not be covered by fixed facilities as well as supporting the fixed facilities and improve beneficiaries access to them through the communication role that will be played by the outreach teams. The project plans to target the urban and rural areas in five Governorates, namely, Ibb, Rhymah, Al Bayda, Ad Dalea, Sana’a. In Aden, the project will target rural areas.
As a main requirement by the World Bank, this Environmental and Social Impact Assessment (ESIA) aims at ensuring that all environmental safeguard are addressed. It also seeks to analyze the social context, initiate a process of community participation, and provide guidance for project design and implementation.
1 Estimation calculated against 2004 census with 3.02% annual population growth. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
The ESIA team worked according to the terms of reference (ToRs) that include the various tasks of the ESIA. The ESIA has been implemented using a four phase approach: • The description of the current situation/ baseline analysis • Analyzing results and preparing the draft ESIA • Presenting results and consulting with stakeholders • Preparing the final ESIA and disclosing the report
The ESIA report includes a legislative framework including all the laws and regulations relevant to the issues that concern the project. The legislation framework involves all the Yemeni Laws, World Bank safeguard policies of relevance to the project and the international conventions ratified by Yemen. The main Yemeni legislation includes the Yemeni Constitution, Environmental Protection law 26 of 1995, Public Health Law 4 of 2009 and the Medical and Health Facilities Law 60 of 1999. The World Bank Safeguard policies included were those of relevance to environmental assessment and public disclosure, while the international conventions included the Convention on the Rights of the Child (CRC).
The predicted environmental and social impacts of the project have been analyzed using the background and the description of the project and guided by the primary and secondary data reviewed by the consultant. This analysis, generally, indicated that the project would result in many positive effects, especially for women, infants and children who are among the most vulnerable groups in need of improved health conditions.
The ESIA study showed that on the environmental level, some negative impacts related to chemical handling, the waste generated from different departments, the methods of handling the said wastes and wastewater might be encountered. But these could not be regarded as direct impacts from the project. They are rather general challenges that face the health sector in Yemen. In addition, the ESIA involved examining other impacts related to the use of incinerators, generators, boilers and engines, and the consequent gas emissions and potential oil spills. However, these also concern the healthcare sector in general as they pertain to the services normally provided on a day to day basis whether the project exited or not. The project’s activities contributions to these impacts is very limited and of minor share.
On the social level, there are multiple positive impacts. The ESIA analysis showed that many of the expected social benefits of the project are caused by the fact that the project is dealing with many root causes of the problem, and that the design of the components involved the integration between community-based activities and capacity building activities. The ESIA also proposed a set of recommendations in order to tackle some risks and to maximize the social benefits.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
The expected environmental impacts during the operation phase of the project include the impacts related to the improper handling and storage of chemicals and drugs that could cause the deterioration and corruption of these chemicals and drugs; easy, uncontrolled access of the population, particularly children, to these substances; soil contamination; water contamination; and the increase of the cost of drugs and chemicals. By applying a strict and proper system of storage and safe handling, all these impact could be reduced, or even eliminated.
Also, the improper disposal of HCW generated during outreach medical services, especially used syringes, needles and other hazardous wastes could negatively impact the health of the local community’s inhabitants, especially children. Outreach service providers must take a number of measures and precautions in order to eliminate this negative impact.
Regarding the expected negative environmental impacts to be caused by the mismanagement of the increasing quantities of municipal solid waste generated by the healthcare facilities and despite the fact that these impacts are not as critical as those related to the HCW, The potential complications for public health should not be underestimated. It is, thus, recommended that the project should carry out series of awareness activities for both the human resources in the health sector as well as the local communities to raise the awareness of the hazards of waste on human and environment health.
No considerable negative social consequences are expected to result from the preparation phase. It is thus predicted that the only social impact associated with this stage will be the creation of some local job opportunities for residents providing support to the referral services in the fixed existing health facilities (e.g. transport, etc.).
During operation, it is expected that the project will generate a number of positive impacts. These include the creation of new jobs for community members, particularly women, improving women’s access to maternity health services, improving child health and safety in remote and disadvantaged areas, enhancing trust between beneficiaries and government agencies, building the capacity of human resources raising community awareness, increasing women’s sense of security, improving the process of monitoring and evaluation, and building and enhancing the capacities of human resources of health crew and volunteers in the field of the community health work and outreach services.
Nonetheless, the social risks related to the project are linked to the existing challenge of dealing with the sense of dependency among the local communities that result in full reliance on the outreach services rather than visiting the fixed health facilities. Thus, Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
awareness raising and direct communication - which come on the core of the detailed project activities- are critical components that will encourage beneficiaries to visit the health facilities to achieve higher utilization rates.. The outreach teams, with all the social credibility they have among local communities, will significantly contribute to strengthening the communication channels and ensure positive social outcomes. Moreover, the capacity building of the existing human resources will maximize the benefit from their experiences in both outreach and fixed services.
Furthermore, project sustainability after the termination of the project fund is also an area of concern. The project will seek funding channels and will mobilize resources in the targeted Governorates as well as on the central level from the Ministry of Finance.
The ESIA also recommended establishing dialogue and communication channels between the project and the various donor agencies and coordinate efforts to avoid duplication of efforts and to attain the optimal benefit from the available resources.
The outreach strategy of the project is characterized by being comprehensive. This will largely contribute to addressing the various social risks. The most important activity that will address the social risks, as recommended by the ESIA, are the awareness raising the participatory monitoring and evaluation and the capacity building. the Health and Population Project will establish a Project Administration Unit (PAU) to be the organizational structure in charge of the project under the supervision of the MoPHP The PAU aims to avail the capacitates resources that can ensure the efficient implementation of the environmental and social management plan (ESMP). The PAU will hire environmental and communication strategy consultants. Moreover, a supervisor will be assigned in each of the targeted Governorate.
Conclusion
The Health and Population Project (HPP) planned to be implemented in six of the Yemeni Governorates with funds from the World Bank is expected to result in several environmental and social positive returns that outweigh the limited environmental and social negative impacts that can be mitigated through the implementation of the ESMP. Consequently, it is concluded that the HPP is a socially and environmentally feasible project. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
LIST OF ACRONYMS AND ABBREVIATIONS CBN Community Based Nutrition CHV Community Health Volunteers CMW Community Midwives CRC The Convention on the Rights of Children CSM Contraceptive Social Marketing Project CSO Central Statistics Organization EOP End of the Project ESIA Environmental and Social Impact Assessment ESMP Environmental and Social Management Plan FGDs Focus Group Discussions GoY Government of Yemen GAVI Global Alliance for Vaccines GDFH General Department of Family Health HCRW Healthcare Waste HPP Health and Population Project HRSP Health Reform Support Project HSS Health Sector Strengthening IMCI Integrated Management of Childhood Illnesses ITIFA Independent Technical and Internal Audit JICA Japanese Agency for International Cooperation KFW German Development Bank LBW Low Birth Weight M&E Monitoring and Evaluation MDGs Millennium Development Goals MNCH Maternal Neonatal and Child Health MoPHP Ministry of Public Health and Population MWRA Married Women of Reproductive Age NCHEI National Center for Health Education and Information NGOs Non-governmental Organizations NIC The National Information Center NID National Day of Immunizations Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
OP Operational Policy OTP Outpatients Therapeutic Points PAD Project Appraisal Document PAU Project Administration Unit PM&E Participatory Monitoring and Evaluation PRA Participatory Rapid Appraisal Tools QIP Quality Improvement Program RoY Republic of Yemen SFD Social Fund for Development SSI Semi-Structured Interviews TFC Therapeutic Feeding Centers ToRs Terms of Reference UNICEF The United Nations Children’s Fund USAID United States Agency for International Development USD United States Dollars WB The World Bank WHO World Health Organization WHO World Health Organization YG-RHP The Yemeni-German Reproductive Health Program YR Yemeni Riyal
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
1. Introduction
−˜ł− Background
The geographic and topographic features in Yemen vary among mountains, coastal areas, plains and deserts. The population in the Republic of Yemen was estimated to be 23,208,000. Yemen includes about 136000 inhabited areas located on an average area of 500000 km2. Nearly three quarters of the population live at rural areas. Yemeni Republic faces many population-related challenges, such as: (1) the increased mortality rate of maternal, infants/neonatal and children under five years old (2) The spread of malnutrition among children. (3) The increased rate of population growth. These challenges represent a barrier to achieving the fourth and fifth Millennium Development Goals (MDGs) in Yemen by the year 2015.
1.2 Health and Population Project˜(HPP)
1.2.1 Project Objective
The objective of the proposed Yemen Health and Population Project is to improve access to and utilization of a package of maternal, neonatal, and child health services in selected governorates with a high concentration of districts with poor health indicators.
The Project will contribute to the GoY’s goal of achievement of MDGs 4 (decrease in child mortality) and 5 (improvements in maternal health). Direct project beneficiaries are expected to include the people receiving the outreach services provided through the project’s activities.
The key indicators to measure achievement of the project development objectives include 1) Access to MNCH services due to outreach services and 2) Utilization rates of MNCH services due to outreach services. The IDA project cost is estimated at US$28.0 million
1.2.2 Objectives of the Environmental and Social Impact Assessment (ESIA)
ESIA is a main requirement for funding developmental projects by the World Bank. The Health and Population Project ESIA aims at the following:
ƒ Ensure all environmental consequence of rehabilitation and operations of primary health care facilities are evaluated and addressed as part of the mitigating measures incorporated into the project design and to ensure compliance with World Bank operating policy OP 4.01 on environmental safeguards. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
ƒ Analyze the social context and social issues, as well as the distributional impacts of the intended project services on the different stakeholder groups, in particular Component 1, at the service delivery level; ƒ Initiate a process of stakeholder/beneficiaries consultation and participation which will feed in Component 2 in terms of the impact evaluation process and results-based monitoring system to be put in place and ƒ Provide guidance for project design and implementation arrangement that enhance equitable access to the project benefits and community participation in project implementation and monitoring. ƒ The ESIA also provides environmental and waste management guidelines for health facilities.. Environmental compliance monitoring of facilities will be done by the PAU in close coordination with Ministry of Water and Environment, the primary environment agency in Yemen. This includes fixed (constructed) healthcare facilities as well as mobile (outreach) healthcare facilities
1.3 ESIA Methodology The ESIA team worked according to terms of reference (ToRs) which included a description of the necessary tasks, the team adopted a methodology that encouraged the active participation of the concerned stakeholders especially the targeted beneficiaries. The preparation of the study involved three main phases, as follows:
1.3.1 Phase One: Description of the Current Situation
This phase included data collection from various sources with the aim to provide full description fro the project’s relevant backgrounds. These steps included reviewing several available secondary sources of data such as reports prepared by MoPHP, Yemen and other stakeholders specially donor agencies such as the World Bank and other United Nations organizations (UNICEF and WHO), and other private agencies working in the field of mother and child health. The web search has also contributed to a great extent in enriching these secondary sources. These collected secondary information shed the light on the following:
ƒ Social and demographic background of target communities.
ƒ Indicators related to MNCH.
ƒ General backgrounds related to MNCH in Yemen as general and at target governorates in particular.
ƒ Challenges facing workers in the field MNCH, especially the challenges related to achieving MDGs 4 and 5 related to reducing infant mortality rate and improve mother health. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
ƒ Public allocations for MNCH services.
In addition to that the EISA team has conducted several field visits and meetings with the concerned stakeholders. These meeting have contributed to providing in depth qualitative information. The meetings helped also the team to measure community perceptions and benefit from previous experiences. The interviewed groups of stakeholders included:
ƒ Government officials on the central level ƒ MoPHP, especially the departments of relevance to the project ƒ Government officials and service providers at health facilities in target governorates. ƒ Different community groups in the targeted Governorates. This included: ƒ Women (groups of newly wedded wives, groups of ladies age forty) ƒ Husbands ƒ Mothers- in- law ƒ Non governmental Organizations (NGOs) ƒ Donor agencies and private sector.
Annex 1 includes a list of the names of the most important interviewed stakeholders.
1.3.2 Phase Two: Analyzing Results and Preparing the draft ESIA
The primary and secondary collected information were analyzed and presented in the project draft EISA. The draft report resented of the different issues included in the mission TORs.
1.3.3 Phase Three: Presenting Results and Consultation with Stakeholders
It is planned in this phase to present the draft results to the MoPHP, and other related stakeholders. To ensure the transparency of the study; the ESIA results will be presented in a consultation session including all concerned stakeholders. This session will be announced and all the concerned stakeholders or their representatives will be invited. This phase aims to bring stakeholders with different affiliations together to discuss and comment on the ESIA findings.
1.3.4 Phase Four: Preparing the Final ESIA and Disclose the Report
At this phase the project team will incorporate the comments of MoPHP and other participating stakeholders to formulate the final ESIA. According to World Bank policy of disclosure the final report will be disclosed.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Chapter Eight will include the presentation of the main results and the output of consultation activities with stakeholders.
1.4 The ESIA Challenges and Methodology Strengths
Several challenges have been encountered by the ESIA team. This mainly involves the lack of comparable indicators which challenged the team and did not allow from conducting a comparison of the situation at different target governorates2. Moreover, the limited time allocated for the preparation of the ESIA accompanied with the difficult geographic conditions at Yemen in general and at target governorates in particular which resulted in consuming time to access various destinations. In addition to this, the defined project activities have not been determined until the date of producing this report.
In the meantime, practical application of the field work tools like focus group discussions and in-depth interviews encountered the well-known challenges associated with qualitative tools application like subjectivity and the influence imposed by the group dynamics and the role of this influence in coloring the findings. The team, however, paid early attention to these challenges through considering the homogenous composition of the groups.
Despite these challenges, the team believes that the adapted methodology used in preparing the ESIA included several strengths that contributed to the quality of the ESIA. This most importantly include:
ƒ The ESIA involved a balanced mixture of quantitative information collected from previous reports and statistics as well as in-depth qualitative data collected through employing several tools such as Focus Group Discussions (FGDs), Semi-Structured Interviews (SSI) and in-depth interviews in the field. This has been an efficient methodology that assisted in understanding the current situation, challenges, perceptions and previous experience in a sense that enriched the ESIA.
ƒ Adapting participatory mechanisms that were highly sensitive to the local and gender related conditions such as: cooperating with female local facilitators to interview women and male local facilitators to interview men. In addition to choosing the appropriate timings for each group, and holding the interviews at convenient locations for the interviewees. These mechanisms helped at gaining the trust of the targeted groups.
2 It was noted that there is relative availability of data/indicators in the governorates where donors have already worked such as Al Dahla’a or Governorates and other Governorates where donors are still working such as Ibb where the Yemeni – German Health Program is still operating. ˜ Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
ƒ Giving the opportunity to all concerned stakeholders in identifying the social impacts and expected fears related to the project. This has boosted the spirit of ownership to the project since early stage. This is seen as a positive introductory action that is predicted to contribute to encouraging stakeholders in participating to all project activities.
ƒ The ESIA team was very alert to the issue of social diversity. The differences in identities and interests among the different groups of stakeholders were highly considered (age, social backgrounds, and gender).
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
2 Legislative Framework
2.1 Laws Related to the Environmental Impact Assessment
2.1.1 Environmental Protection Law No. 26 of 1995
This law sets the general framework of Environmental Affairs and its biosphere in the Republic of Yemen, which is reflected in manifestations of life forms, and its cosmic components. It also includes the living organisms such as man, plants, animals and natural resources such as air, soil and water, as well as the organic and non-organic substances and the natural and human systems, including all manmade elements such as buildings, roads, bridges, and airports, means of transportation and all other industries and inventions.
This law consists of 94 articles including all aspects of environment protection, combating pollution, protecting society, and the implementation of international commitments. It is organizing work according to environmental norms and standards and technical specifications, licensing and approvals for activities, responsibilities, tasks and priorities.
The second article of the law includes all definitions and terms related to the ESIA which states that the ESIA is a detailed feasibility study for the related environmental impacts of the proposed developmental projects.
As stipulated by articles (9) and (24) the need for conducting environmental impact assessment studies for projects to identify and determine the vulnerability to the natural environment and to take necessary mitigation measures to prevent damage.
In addition to all of the above, the third chapter includes the necessary requirements, procedures and parameters related to issuing permits for development projects and the required ESIA. Article (37) identifies the general principles and explanations for the study of environmental impact assessment for projects.
2.1.2 Law 40/1999, the Law of Hygiene
This law has been issued on the 9th of August 1999. Article (3) of this Act sets forth the objectives aimed by that law. This includes: 1. Protection of the environment and the health of society; 2. Disposal, reuse, treatment or reclassification of waste using scientific methods; and 3. Establishment of the principle of decentralization in general cleanliness activities in different administrative units. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Article (2) puts up the definition of different types of waste generated and identifies generators of each type and means of transportation.
Article (17) stipulates that each city or several cities must have waste dumpsites within its vicinities. These dumpsites should be selected to be on a proper distance taking into account health and environmental requirements. The Ministry of Public Works and Roads is responsible for management and operation of dumpsites and the responsibility of waste disposal methods taking all necessary measures to prevent any adverse health or environmental.
Article (19) obliges the owners of special waste such as remnants of hospitals, pharmacies, medical laboratories and industrial waste, generating solid and liquid waste, as well as transport and waste residues to take all arrangements needed to separate this kind of waste from other types of waste.
Penalties as stated by article 23 vary from imprisonment for a period of three month to one year, to paying a fine not exceeding five hundred thousand riyals in case of violations.
2.1.3 Law 60/1999 for Medical and Health Facilities
This law aims to regulate the services, medical facilities and health institutions according to regulations and standards of scientific modern art, and to ensure the upgrading of nature and quality of humanitarian services.
Article (18) is concerned with the requirements that should be provided within the used building ensuring that it satisfies the conditions of health standards according to the type and nature of the entity. Such requirements include the availability of the proper means of safe waste hazardous waste disposal, as well as the engineering specifications based on the law and executive regulations.
Article (31), obliges the constitution of auditing and inspection committees in all governorates of the Republic and the Secretariat of the capital, by the decision of the Minister of Public Health based on recommendations from the Committee on the medical facilities and health institutions, and in coordination with the General Administration of medical facilities and health institutions in the Ministry of Public Health and its branches in the provinces and the secretariat of the capital. Article (30) has allocated the technical and engineering requirements for medical facilities and health institutions. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Penalties According to Article (32), anyone who violates the provisions of Article (18) specifications for buildings, medical and health facilities should be punished by imprisonment for a period not exceeding one year or fined not more than (500,000) five hundred thousand riyals, and the penalty is doubled in case the action is repeated. Article 63 states that any person who violates the provisions of Articles (13) to (18) should be punished.
A fine of not less than (250,000) two hundred and fifty thousand riyals and not more than (500,000) five hundred thousand riyals, and in case of recurrence doubled the penalty, and if the facility refuses to pay and gives the fine 60% to the state treasury and 20% to the competent department and 20% supplied to the competent management of a special account at the Ministry.
Article (64) states that any person who violates the provision of the law should pay a fine of $ (50,000) fifty thousand riyals, 60% of which is supplied to the state treasury and 40% to the competent management of a special account at the Ministry, and if the facility refuses to pay such a fine, records and reports are sent to the prosecutor to take legal proceedings.
As stipulated by Article (65), a temporary closure of the building should take place if it does not satisfy the minimum specifications and equipment contained in Article (64) of the regulation. Article (66), state the cases when closure should take place without failing to meet the provisions of Articles No. (32), (33), (34) as well as Articles (63) to (65).
According to Article (69) any facility that does not adhere to renewal every two years and before the expiration of the imposed term by a fine equal to three times of the fees, and if it exceeds a period of 6 months in the non-renewal, the license would be cancelled resulting in closure and withdrawal of the license.
This article has also emphasized the fine payment which is not more than (500) thousand riyals but it has omitted the imprisonment term that was provided in Article (32). The article has also established a minimum fine of not less for (250,000) thousand riyals.
According to Article (47), the Constitution of the Republic of Yemen that there is no punishment except as legally defined by law.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
2.1.4 Law 39/1999 about Public Hygiene
This law is concerned with organizing the general framework for handling and managing all types of wastes related to humans, public institutions, residential and non residential areas, factories, camps, settlements, yards, slaughter houses, public utilities, tourist areas, gardens and others, means of transportation, car bodies, equipment, machineries or spare parts. Organic wastes caused by animals or remnants of dead animals and construction and demolition waste, dust, and all the consequences of the random dumping of these wastes on the health and environment including fires and visual pollution.
The law also specifies the tasks and responsibilities of all stakeholders who are responsible on handling all sorts of wastes including waste generators and collectors as well as the authorities and public or local bodies that organize and monitor handling of wastes inside the country.
The law also aims at protecting the environment and public health and avoiding any potential negative impact. It sets regulations for the hygienic disposal at cities and villages in a healthy and safe method. In highlights the importance of decentralization and organization of cleaning activities and the required procedures for preparing the general cleaning plans within the boarders of each administrative division.
2.1.4.1 Article (19) Concerning Healthcare Waste
Law (39) for the year 1999 about public hygiene includes article (19) related to special wastes, such as hospitals, pharmacies, laboratories and industrial solid or liquid wastes. In addition to wastes caused by means of transportation, fast decaying waste, such as wastes caused by slaughter houses, meat, chicken or fish markets, shed remains, livestock and poultry remains and others. It stated the necessity of making the necessary arrangements for separation of waste at source. The regulations of this law include all the specifications and conditions related to collecting, transporting and storing these wastes with regards to the applied regulations.
Table 2.1 International Environmental Conventions Ratified by the Republic of Yemen International Conventions Date of Signature Date of Ratification
Convention on Climate Change June 1992 3/12/1995 International Convention on biological June 1992. 3/12/1995 diversity. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
International Conventions Date of Signature Date of Ratification
Montreal Protocol on Substances that Deplete June 1992. 3/12/1995 the Ozone Layer, the London Amendment, the Copenhagen Amendment. Vienna Convention for the Protection of the June 1992 3/12/1995 Ozone Layer. Basel Convention on Transboundary June 1992. 3/12/1995 Movements of Hazardous Wastes and their Disposal, across the border. The International Convention to Combat October 1994 31 / 12/1996 Desertification. International conventions on endangered March 1993 5/1/1997 species of flora and fauna of the wild The Stockholm Convention on Persistent December 2001 Not yet Organic Pollutants (POPs). Convention on Wetlands (RAMSAR) 2002 08/02/2005 Migratory Birds Convention (CMS) May 2002 Rotterdam Convention on Prior Informed May 2002. Consent Procedure for Flag of certain chemicals and pesticides in international trade (PIC). Biosafety Protocol. October 2004 Basel Protocol on Liability and Compensation November 3, 2004 for Damage Resulting from Movements of Hazardous Wastes and their Disposal, across the border. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
2.2 Laws Related to Social Impact Assessment
2.2.1 Yemeni Constitution
The Yemeni constitution regulates some issues related to public health and providing healthcare services. Among the most important articles that discuss these issues is article 32 of part one. It states that education, healthcare and social services are the basis for the social development. Civil society in collaboration with the state should work to provide these services. Article 54 of part two of the Constitution states that healthcare is a right for all citizens, thus the state provides this right by establishing hospitals and healthcare facilities. The law regulates the practice of medicine and the provision of free of charge health care services and spreading awareness among citizens.
2.2.2 Local Administration Law (number 4/2002)
This law grants the right for the local authority to participate in all aspects of health system. According to this law the administrative bodies at the governorates or districts, represented by the elected members of the Local Councils in addition to the Governor or the General Secretary of the governorate or the district are authorized to plan, prepare budgets, and manage human resources and infrastructure related to healthcare field. This law is related to the process of decentralization adopted during the renovation of healthcare sector.
2.2.3 Public Health Law (number 4/2009)
This law consists of 77 articles distributed among 16 chapters discussing the terminology, concepts and goals of the law. In addition to the role of MoPHP and its responsibilities related to MNCH, epidemiological surveillance, combating illness, providing potable water and sewage, professional health, health awareness and avoiding impacts of chemical materials.
The law in chapter 4 – the most related chapter to the project – discusses all aspects of MNCH including the state commitments represented in the MoPHP to provide therapeutic, preventive, diagnostic and rehabilitation services related to MNCH. These services include providing medical care for pregnant women during pregnancy and at birth, raising awareness about suitable child nutrition and care, programs for follow up of child growth. This chapter also discusses the role of the ministry in providing preventive services for school children and nurseries, and in preparing and implementing vaccination programs and the safe handling of the immunizations, the law forces the parents to submit the children to mandatory vaccination program.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
2.2.4 Presidential Decree (number 76/2004)
In accordance with this decree the population sector was founded in the MoPHP, which includes the General Department for Women Development, the General Department for Heath and Population Education, and the Department of Reproductive Health.
2.3 International Regulations Related to the Project
2.3.1 The Convention on the Rights of Children (CRC)
The CRC is one of the United Nations conventions that has been ratified by Yemen in May 2001. Among the most important and relevant articles of the convention are the articles regarding the responsibility of both the state and parents –being the primary duty bearers- with providing the child's rights and supporting participation and empowerment. The convention also includes the role of the state in providing the child with different types of services including healthcare services, mentioned in article 24, which indicates the following:
1. States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services. 2. States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures: (a) To diminish infant and child mortality; (b) To ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care; (c) To combat disease and malnutrition, including within the framework of primary health care, through, inter alia, the application of readily available technology and through the provision of adequate nutritious foods and clean drinking-water, taking into consideration the dangers and risks of environmental pollution; (d) To ensure appropriate pre-natal and post-natal health care for mothers; (e) To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation and the prevention of accidents; (f) To develop preventive health care, guidance for parents and family planning education and services.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
2.4 World Bank Safeguard Policies
The World Bank has identified 10 safeguard policies concerning environmental and social protection, which should be taken into consideration for projects to be funded by the bank. The purpose of these policies is to eliminate the impacts of the development process on human beings and their environment. Below are the related policies to project activities:
2.4.1 Environmental Assessment Policy (OP 4.1)
It is one of the World Bank protection policies and one of the main requirements for projects funded by the World Bank. According to this policy, the concerned government should conduct an EIA study for the planned project in order to ensure that the project does not have reverse negative impacts on the environment. As well as provide the necessary mitigation measures regarding these impacts from the early stages of the project, to ensure no harm will be done to the environment.
2.4.2˜Disclosure Policy (OP 17.50)
The World Bank policy number 17.50 about disclosure and dissemination of information states that it is the right of communities to be aware of the planned projects and indicates their right for monitoring of the projects in order to make the proper decision concerning the projects based on the information about development. The disclosure policy includes details about: disclosure concepts, exceptions for disclosure of information, routine disclosure processes, and disclosure upon request. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
3. Health and Population Project (HPP)
3.1 Project Objective
The Health and Population Project (HPP) is a project with planned fund form the World Bank. It aims through its two components at improving and supporting the provision of Maternal Neonatal and Child Health (MNCH), in addition to improving child health at target areas suffering from deteriorated health indicators due to accessibility challenges. The Project will contribute to the GoY’s goal of achievement of MDGs 4 (decrease in child mortality) and 5 (improvements in maternal health). Direct project beneficiaries are expected to include the people receiving the outreach services provided through the project’s activities.
The allocated budget for the project is 28 million USD. The project will be implemented in priority rural areas in 6 Governorates, namely Sanaa, Ibb, Reimah, Al Baydah, Al Dahla'a and Aden3 in the duration between 2011 to 2015. The project encompasses two main components, namely: (1) Acceleration of MDGs 4&5 (estimated US$25.3 million) and (2) Results-Based Monitoring, Evaluation, and Project Administration (estimated US$ 2.7 million).
3.2. Project Description
Component 1: Improving Access to Maternal, Neonatal and Child Health Services (US$25.3 million). This component would support initiatives targeted to improve access to MNCH services in geographic areas with poor MNCH indicators. Activities would include delivery of outreach services and selective upgrading of first level referral facilities. It would comprise three subcomponents.
Sub-Component 1.1: Delivery of Outreach Services (estimated US$17.2 million). This sub-component would support the following set of activities:
• Provide/expand access to a basic MNCH package of services to populations with no or limited access to health services, using a service delivery model of routine mobile outreach health services (Outreach)4. This model will complement service delivery in fixed facilities as well as community-based services provided through GoY and development partner resources.5 It will also increase the demand for the delivery of services through fixed facilities and strengthen referral of cases to these facilities.
3 In Aden governorate, the project will support Outreach services in its rural district (Boureika) and its urban slums districts (Dar Saad, Sheikh Othman, and Crater). 4 The project divides the outreach service areas into three main levels. The first level is the locality near the health facility and the second level is the locality within less than one hour walking distance from the health centers and third Level area, beyond one hour and half drive. 5 UNICEF will be supporting community-based services in the governorates of Sana’a and Ibb to complement the routine outreach services supported by this project in these two governorates. JICA is supporting community-based services in six districts in Yemen in three governorates, two of which (Sana’a and Ibb) are to be supported under the HPP. Community-based services design and plans are based on the experience that was implemented by the GAVI- Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
• Integrate reproductive health and nutrition services within Outreach Services.6 • Integrate the routine delivery of selected vertical public health programs, such as Malaria and Schistosomiasis, within Outreach Services.7 • Make available essential drugs, diagnostics, supplies, and equipment for MNCH services (including contraceptives) for Outreach Services. The project will also support strengthening the logistics management system for Outreach Services to ensure the timely availability of quality drugs and health commodities. • Strengthen health management information systems and quality assurance that would ensure the proper functioning and monitoring of Outreach Services. • Make available program operating costs necessary to roll out Outreach Services.
Rolling out of Outreach Services: Specifically, the sub-component would support, in the project governorates, a population-based program that delivers a basic package of MNCH services in rural and urban slums districts through an enhanced model of Outreach Services, building upon the service delivery model developed under the GAVI- funded HSS project, which is scheduled to complete in 2010.8
Geographic Targeting: The package of MNCH services are to be provided initially in priority rural areas in the following governorates: Sana’a, Ibb, Reimah, Al Dahla’a, Al Baydah, and urban slums in Aden9,10 before rolling being rolled out to additional rural governorates. The delivery would be rolled out gradually in a phased and incremental approach based on a roll out plan.
Communication Strategy: The service delivery model would be complemented with demand side activities through the design and implementation of a communication and social mobilization strategy and detailed action plan. The overall goal of this strategy will contribute to the HPP project objectives of improving access to MNCH services in geographic areas with poor MNCH indicators as well as the delivery of outreach services
funded HSS Project. Collaboration with the Social Fund for Development to support community-based services is being explored. 6 Currently the package of Outreach Services focuses primarily on immunization and other basic child health services such as IMCI. Only Sexually Transmitted Diseases (STDs) from reproductive health services are incorporated within the package. 7 Drugs and impregnated bednets will be supplied by the respective national control programs for schistosomiasis and malaria financed by the IDA financed project, Schistosomiasis Control Project, and Global Fund Project. The HPP will finance the operating costs necessary to improve the routine coverage. 8 The design of the interventions also takes into consideration the relative strengths and lessons learned from a host of other initiatives, including the district level planning process of the HRSP, the MOPHP’s EPI program, and the Dutch- financed MNH program. 9 The governorates were selected through the following process: The relative ‘riskiness’ of each district was evaluated using the following criteria: population density, immunization rate for children, tetatus toxoid immunization rate for women, and ratio of deliveries attended by skilled health personnel. Based on these criteria, 100 districts with poor indicators were identified and grouped by governorate. The governorates with the most concentration of districts with poor indicators were selected. 10 In Aden governorate, the project will support Outreach Services in its rural district (Boureika) and its urban slums districts (Dar Saad, Sheikh Othman, and Crater). Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
and upgraded first level referral facilities. The impact of the communication interventions will contribute to reduction of morbidity and mortality and improvements in health status.
The objective of the communication strategy will be to: (i) promote the benefits of the new integrated service delivery model; (ii) raise public awareness about the availability of the outreach services interventions as well as the routine-based preventive services through fixed facilities and community-based services, to contribute to increased service utilization and compliance; and (iii) promote behavior modification among targeted communities to improve utilization of low demand services such as maternal health, family planning, and nutrition. The key message would be that attending outreach services at regular intervals and visiting fixed health facilities in between, or seeking services at the first referral level of health facilities for complicated cases will result in reduction of morbidity and mortality and improvements in health status. In support of the above, the strategy will include capacity development of the Outreach Services program in terms of communication planning and implementation.
This sub-component will support a formative research study to identify communication needs, key behaviors, targets, beneficiaries, and influencers for child and maternal health and nutrition and prepare a communication strategy and plan in the first year of project implementation. The strategy will propose key messages to disseminate, communication channels and media to be used, and training requirements.
Outreach Workforce Development: In addition, this sub-component would strengthen the capacity of the health workforce to administer and deliver basic MNCH services through Outreach Services through the development of manpower training programs, with priority focus on midwives and health administrators. In the project governorates, the component would support the roll out of this upgraded manpower training program.
Systems for Outreach Services: This sub-component would focus on strengthening the systems which support the effective delivery of Outreach Services in the project governorates. It would finance technical assistance to assess options for improving: (i) the logistics management system; (ii) health management information systems (HMIS); and (iii) quality assurance systems for Outreach Services. Based on the findings of the technical assistance assessment, selected applications of the above would be adopted and financed in the project governorates.
Sub-Component Inputs: The inputs to this sub-component would include financing for: (i) Outreach Services program operating costs; (ii) procurement of essential drugs, diagnostics, kits, equipment, and supplies (including contraceptives) and other related health commodities which are not currently available through the MoPHP or other donors; (iii) training workshops for health workers, midwives, and health administrators; (iv) design and implementation of communication and social mobilization campaigns; (iv) costs of printing of communication and training materials, production of TV spots, and other capacity-building materials; (v) provision of technical assistance and procurement of goods to apply logistics management, health management information, Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
and quality assurance systems for Outreach Services; (vi) procurement of IT equipment, software, and their related training; and (vii) consulting services to support the above.
Sub-Component 1.2: Upgrade of First Level Referral Facilities and Provision of Community-Based Services (estimated US$6.1 million). This sub-component would support the following set of activities:
Referral Centers: Outreach mobile teams and community based workers will identify and refer complicated cases which require additional services to the appropriate level of fixed facility. This sub-component will provide targeted resources for basic equipment and drugs, and training for physicians, health workers and midwives at health facilities in the project governorates to ensure that (at a minimum) the following services are available: (i) EMOnC (the referral services for reproductive health); (ii) TFCs/OTPs (the referral services for nutrition); (iii) referral services for IMCI; and (iv) Basic Emergency Services.11 Project-financed investments will complement those of ongoing government and development partners programs which are investing in EMOnC12, TFC and OTP 13 services in the project governorates. Support will also be provided to meet the PHC service requirements for the population residing in the catchment area of these facilities.
Community-based Delivery Services: This sub-component will support strengthening community-based health services and home-based delivery services. This would include the procurement of basic drugs and equipment and training of midwives as follows: (i) two to three years training to produce new midwives to cover existing workforce gaps in the project target governorates; (ii) one month training for existing midwives to upgrade their skills; (iii) training of community health volunteers; and (iv) procurement of kits and supplies for community-based services and home-based delivery. Through these investments, it is expected that the midwives will be better able to support home-based deliveries, referring the risky and complicated cases to the first level referral facilities as needed. CHVs will be able to provide health education activities and active case finding of complicated cases and their referral to the appropriate level.
Sub-Component Inputs: The inputs to this sub-component would include financing for technical assistance to develop health as well as investment plans, the procurement of medical and non-medical equipment, supplies, drugs, and laboratory equipment and targeted infrastructure investments, and training workshops for health workers, including midwives and community health volunteers.
11 It is expected that about 70 first level health facilities will be targeted under the project. Technical assistance will be provided to develop health and investment plans for the first level referral facilities in the project governorates. These plans would identify facilities for investment under the project that have high utilization rates, are operational and have adequate capacity to delivery services, and are accessible to the population in the project governorates. 12 Expected to be funded by UNFPA and the Dutch (10 governorates to be expanded to 22 governorates) through a national plan to roll out EMOnC services that will be developed by UNFPA. The Social Fund for Development is also contracted by the Dutch to roll out EMOnC services. 13 Expected to be funded by UNICEF through a national plan to roll out TFCs and OTPs that will be developed by UNICEF. The EU provided a 5 million Euro grant, managed by UNICEF, to roll out additional TFCs and OTPs. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Sub-Component 1.3: Support National Immunization Campaigns (estimated US$2.0 million). This sub-component will support funding gaps in investments for the implementation of one national vaccination campaign for measles for children under five to contribute to the elimination of measles in Yemen and to complement the earlier efforts financed by IDA under the HRSP.14 It will also support expansion of the implementation of campaigns for vaccination of Tetanus Toxoid (TT) for women 15-49 years old.
Sub-Component Inputs: The inputs to this sub-component would include financing for vaccination campaigns operating costs.
Component 2: Results-Based Monitoring & Evaluation and Project Administration (estimated US$2.7 million). The project would finance technical assistance to carry out evaluations of the upgraded MNCH Outreach Services to measure the results of the project interventions on the access and utilization of women and children in the project governorates. The evaluations would include a baseline survey, mid-term and end of project evaluation. In addition, this component would support activities related to the design and implementation of independent monitoring of project targets and audit of Outreach Services. It will also support, with other development partners, two rounds of national Demographic Health Surveys. The first is expected to be carried out in the first (2011) and last (2016) years of project implementation.
Project Administration Unit: The component would also provide project management support (consultancy services, equipment/supplies, and operating expenses) to support the establishment and operation of a Project Administration Unit (PAU) within the MoPHP. The PAU reports directly to the Deputy Minister of Health of Primary Health Care and is led by the General Director of Family Health. It is to be attached to the GDFH to administer the Grant funds and to provide full time administrative and technical support with close administrative proximity to the Outreach Team to support their efforts to implement the HPP. The PAU will consist of: (i) Project Administrator; (ii) Procurement Officer; (iii) Financial Officer; (iv) Accountant; and (v) Secretary. The PAU will be complemented with the services of an Independent Technical and Internal Audit (ITIFA) for the duration of the Project.
The PAU will have the following key functions: management of project monitoring & evaluation (M&E), and financial and procurement management. The PAU will: (i) assist the Outreach Team in the project implementation and manage the resources of the Project; (ii) facilitate efforts to conduct an early mapping survey and a baseline survey, monitor and evaluate the project targets, and evaluate the project results in coordination with the Outreach Team; (iii) handle procurement, financial, and disbursement management, including the preparation of withdrawal applications under the Project; (iv) ensure that an independent audit of the project is carried out on an annual basis; (v) prepare the financial and procurement sections of the quarterly Progress Report and consolidate with the technical part prepared by the Outreach Program for submission to
14 The national measles campaign is planned to be implemented in 2012. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
the Steering Committee (SC) and IDA; (vi) act as the liaison between the Outreach Program and IDA; (vii) ensure that all reporting requirements for IDA are met according to the Project legal agreement; and (viii) provide secretarial services to facilitate the activities of the Steering Committee (SC).
Component Inputs: The inputs to this component would include financing for: (i) the provision of technical assistance, equipment and supplies to conduct the independent monitoring, audit, and project evaluations as well as monitoring of the project; (ii) the provision of technical assistance and procurement of goods for the implementation of national demographic health surveys; (iii) the provision of technical assistance to monitor environmental safeguards; (iv) the organization of training workshops, conferences, and events to dialogue, discuss, and reach consensus on the above mentioned activities; and (v) the provision of technical assistance for project administration, in addition to operating costs, and procurement of equipment, office furniture and supplies to support the PAU. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
4. Description of the Environment and Socio-economic Conditions
4.1. Description of the Environment
4.1.1 Location
Yemen is located in the south-western corner of the Arabian Peninsula, which is south- western Asia. It is bounded from the north by the Kingdom of Saudi Arabia, from the south by the Gulf of Aden and the Arabian Sea, from the east by Oman and from the west by the Red Sea. Yemen oversees the Strait of Bab al-Mandab one of the most important waterways in the world, which connects the Arabian Sea, and the Red Sea. Compounding the importance of the location of Yemen is the spread of islands in its territorial water along the coasts of the Arabian Sea, the Gulf of Aden with the Red Sea.
Figure 4.1 Map of Yemen
The total arable land is estimated by about 7% of the total area of Yemen, the actual total cultivated area is about 29% of the arable lands.
The total population of Yemen is about 23,208,000, of which 66% are living in rural areas; the average population density is about 27 inhabitants / km2. Unlike the western part of the country, where the population density reaches about 300 inhabitants / km2 in the governorate of Ibb, the three Eastern provinces on the other hand do not suffer from the same problem, the population density is less than 5 inhabitants / km2, and this is mainly due to hard environmental conditions.
The majority of the population lives in the mountains area of Yemen in the western part of the country, due to the availability of irrigation water from rainfall. Also, a big portion – if not the majority - of the population are living in different desert locations in eastern highland areas. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Figure 4.2 Map of Land Usage in Yemen
4.1.2 Geological and Hydrological Characteristics of Yemen
4.1.2.1 Terrain
Yemen is characterized by a remarkable diversity of the terrain surface, and thus it is divided into five major geographic regions which are:
1. Coastal plain region: this region is extended and non-connected along the Yemeni coast, with mountains and hills cutting at different areas, reaching directly to the sea at more than one place, and because of the presence of these mountains, this region contain many plains and valleys, including:
Tihama plain - Tibn/Abin plain – Mayfa'a Ahour plain – the eastern coastal plain a part of Mahra governorate.
The Coastal Plain region is characterized by a hot climate all along the year. Although rain fall is relatively low, with a rate ranging between 50-100 mm per year, it is considered to be as one of the important agricultural regions in Yemen, which depends primarily on the large penetrating valleys, in which the flood water falling from the mountains is usually poured.
2. The Mountainous Highlands Region: this includes the mountains of the basin of Sanaa, Rida, Ibb and El Bayda. This region extends on the west side of the country, from the furthest borders of Yemen in the north, until the far south. This region have been Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
subject to tectonic movements resulting in primary and secondary faults, some of which along the Red Sea and others are along the Gulf of Aden, resulting in highland pop ups confining some mountain basins called bottoms or fields.
The Territory is rich in surface valleys bounded by very steep borders, acting as a mountain shields overlooking the Tihama plain with steep slopes, these mountains are considered to be the highest in the Arabian Peninsula, where the average height in about 2000 and the peaks reach more than 3500 m and the highest peak is about 3666 m as is the case of Mount of Prophet Shuaib. Water descends through a number of valleys from east, west and south, the most important valleys are: Wadi Moore - Harad - Zobaid - Seham - and Wadi Rcian. These wadis all flow into the Red Sea. The other valleys draining into the Gulf of Aden and the Arabian Sea, the most important of which are: Wadi Tibn, Wadi Bena, and Wadi Hadramout.
Figure 4.3 Important Valleys in Yemen
3. Mountain Basins Region: this region is represented by the plains and basins in the mountainous highlands, mostly located in the eastern part of the water division line extending from the far north to the far south, including: Qa’ Yariem- Thamar – Ma'bar – Haod Sanaa – Sa'da.
4. Plateau Areas Region: this region is located to the east and north of the highlands region and parallel to it. This region, on the contrary, expands more towards Al Rob'a Al Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Khaly and its surface declines gradually to the north and east. This surface constitutes mostly of a desert rocky surface with some of the valleys passing through, especially the valley of Wadi Hadramaut and Wadi Harib.
This plateau is divided into two parts: The western plateau: consisting of igneous, archaic and metamorphic rocks called (Furnace), the plateau reaches its maximum height in the west of about 3300 m, near the strait of Bab el Mandab. The height decreases towards the east to reach about 2000m.
Hadramout plateau: it is the eastern plateau, and it is also divided into two main parts separated by Hadramout valley.
Southern Hadramout plateau: its height is about 1230 m, and it decreases towards the east to about 615m.
Northern Hadramout plateau: its height reaches about 1350m, and in the east about 500m.
5. The Desert region: Sandy region almost devoid of flora except in parts of rainwater streams from mountainous areas adjacent to this region. The altitude of the surface in the region is between (500-1000) m above sea level sloping without terrain interruption towards the north-east to the center of Rob’a El Khali, an area of severely hot climate characterized by severe continental climate, big temperature range, rare rain, and low humidity.
Figure 4.4 Geographic Regions in Yemen Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
4.1.2.2 Soil
Yemeni soil is characterized by noticeably soft touch, as it consists of several substances such as sand-shale, plastic clay, and silty clay. The degree of alkalinity or pH of the soil is between 7 - 8.5 degrees, and the Yemeni soil is characterized by noticeably developed structures but very weak in terms of coherence. The main types of soil in Yemen are limited to two categories:
Colluvial Soil:
It is the soil formed as a result of the rolling rock debris, caused by the influence of gravity, from the high areas towards the low areas, only for a short distance from the origin. There is much of this type of soil in the desert or semi-desert as a result of the rule of mechanical weathering and the lack of flora, which prevents the movement and falling of disjointed debris. The landslides in all forms are the main reasons for this soil movement, and the granules of these soils are not similar in size, since it is often mixed with large size stone (boulders/pebbles) and this soil is available at steep slopes, which usually does not show good stratified characteristics.
Alluvial Soil:
This type of soil includes all types of soil that were deposited or drifted by the runoff water current, upon contact with water bodies in the form of deltas. This soil is characterized by the capacity of the sediment particles in addition to homogeneity of particles, which are two features that distinguish water sedimentation from other forms. The alluvial soil is available particularly over the flood plains of rivers merged by water from time to time, and there are also deltas, round deltas and long ones. It could also be found on a smaller scope at coastal lagoons and swamps, and at the bottoms of river courses. This may also exist in the floodplain, especially at valleys and at basins in which the torrential rains and floods are flowing. This alluvial soil is usually characterized as thick and fertile, especially if the weather conditions are suitable for quick proliferation of organic materials. Another reason is the ongoing renovation of soil uppermost layer caused by sediments deposited by the almost yearly flood.
The soil in Yemen is subject to strong erosion factors represented in strong wind or rain water or floods. The impact of erosion is increased by the absence of a relatively dense vegetation cover in most areas. This reduces the biological activity, which in turn, is not sufficient for producing the necessary organic content sufficient for the soil binding.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
4.1.2.3 Climate Yemen is overlooking two seas. The Red Sea runs along the western Yemeni coast and the Arabian Sea in the south. Yet, the climate of Yemen has not benefited from the marine characteristics of these two major water bodies, except for raising air humidity on the coast. This is where the impact of these two seas in modifying the characteristics of the climate was only limited to humidity and the change of some wind properties. Meanwhile, their effect on climate’s instability is limited. This might be due to the mountain chains bordering the western and south western Yemeni coast making a barrier to the effect of these two important marine surfaces, greatly reducing their impact on Yemeni interior areas.
Rain usually falls in Yemen in two seasons. The first season is in spring between March and April and the second season is during summer between the months of July and August. The later being the rainier of the two seasons. The amount of rainfall varies greatly, the ranges are spatially extensive and the highest annual amount of rainfalls is in the south western highlands mainly in Ibb, Taiz, Dal’ea and Yarim. The amount of rainfall ranges between 600-1500 mm per annum. It decreases in the western coastal plain as in Hodeidah, Mokha, despite their exposure to the south-west monsoon wind coming from the Indian Ocean and crossing the Red Sea. This is due to the absence of a raising factor for the moist wind. The average annual rainfall increases, though, over elevations, from 50 mm on the coast to about 1000 mm at hillsides facing the Red Sea.
Figure 4.5 the Amount of Rainfall in Yemen Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Similarly, the average rainfall at the southern and eastern coasts of the country does not differ from that at the western coast. Rainfall there reaches the level of 50 mm per year as in Aden, Alfayoush, al-kode and Al-Rayyan. This is due to several factors. This includes the direction of the humid wind moving along and parallel to the coast without penetrating into the interior land. Its impact is very limited, and hence rainfall is not of a significant economic importance.
Concerning the temperature, the eastern and southern plains are characterized by high temperature in summer, reaching up to 42°, and falling to 25° during winter. Temperature gradually decreases towards the higher elevations as a result of altitude. Thus, temperature reaches a maximum of 33° and a minimum of 20°. In winter the minimum temperature on the highlands descends to almost freezing point. During winter of the year 1986, a drop in temperature in Thamar was recorded reaching 12 degrees below zero Celsius.
The relative humidity is high at coastal plains reaching up to more than 80%. It decreases towards the inside, reaching its lowest level in desert areas, where humidity is at the level of about 15%.
4.1.3 Ecological Classification of the Study Area
Yemeni environment is characterized by a rich environmental and biological diversity. The uniqueness of Yemen geographic location at the crossroads of three vital areas, in addition to its habitat diversity that ranges from mountains highlands to plains or deserts or even volcanic islands, all have played an important role in having a rich biological diversity both in land and marine environments. The diversity of climate in different regions of Yemen has led to environmental diversity such as various species of plants, animals and birds. In addition to that the island of Socotra, which is an environmentally exceptional place and represents one of the unique global environmental systems, harbors several endemic species of plants, birds and animals that are not available at any other part of the world, such as the tree of brothers blood, and the Socotra Kat tree in addition to other hundreds of unique species.
4.1.3.1 Environmental Characteristics of the Study Area
According to the ecological classification of the Global Fund for Nature, the study area belongs to the "Southwestern Arabian mountain woodlands", in addition to the area of Aden, which is a coastal oceanic are. This makes the region of a very rich diversity in terms of species and habitats. For that, the area was put on top of the terrestrial ecosystems classification in the world. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
This ecoregion extends to cover an area of about 33,600 square miles, beginning in Egypt in the west and ending up at the Arabian Gulf in the east. Biological components consist mainly of deserts, mountains and wood bushes. It is considered as an environmentally distinct area, which contains unusual ecological elements in the natural ecosystems of the Arabian Peninsula, such as mountain boiling springs, forests and agricultural terraces at very high altitudes.
Figure 4.6: Mountain Agricultural Terraces at the Area of Gebla, Ibb Governorate
The region is characterized by being very rich in floral and faunal diversity. The area represents a habitat for more than 2000 plant species of which about 170 are native species. The area contains mountainous forests that are rich in wild faunal life. The animal diversity is represented in nearly 34 species of mammals, 245 species of birds, 41 species of reptiles and 7 types of amphibians. The overgrazing, erosion and poor maintenance of agricultural terraces, in addition to deforestation and poaching are the major threats to this ecoregion’s habitats.
The region is characterized by the presence of considerably eroded mountains (with shelves), which represents the dominant topographical feature, extending from north to south. The area contains several peaks rising to above 3,000 meters, including Mount of Prophet Shuaib, the peak which reaches an elevation of over 3,760 meters. That makes it not only the highest in Yemen, but in the whole Arabian Peninsula.
The mountains in the region are formed mainly from sedimentary rocks (limestone, sandstone and oil shale), which formed during the Jurassic, Cretaceous, and lower Tertiary periods.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Climate patterns vary greatly in the region. This is depending on elevation and seasons, as well as other factors. Mountains usually receive variable amounts of rainfall caused by humid south-west monsoon wing coming from the ocean. The wind acts as a lift causing thunderstorms, especially during summer, with highest amount of rainfall in April, May, July and August. The average annual rainfall over the mountains is roughly 600-800 mm, increasing to more than 1000 mm at more humid areas. The temperature varies in the region, according to the driving natural factors. It reaches the maximum over highlands during summer, with an average estimate of about 20-25 degrees Celsius. As for winter temperature could attain around 10 degrees Celsius. Although frost may occur several times over altitudes exceeding 2000 m in addition to mountain peaks.
Most forests and woodlots covering the mountains in Yemen have been wiped out and replaced by agriculture activities. Mountains have been converted into agricultural terraces, which is a farming tradition dating back to more than two thousand years in Yemen. This has modified most of natural morphological features even of the steepest mountains. The very little portion of that forest cover has survived this tradition, and can easily be distinguished at present time.
Figure 4.7: Juniper Trees
4.1.3.2 Elements of Biodiversity in the Region
The ecoregion supports about 2000 species of vascular plants, of which about 170 species are endemic, including 2 endemic genera (Saltia and Cenitaurothamnus) (Miller, 1994). Among the most important flora, in particular are the remnants of Juniper forests in Mount Bar’ and Mount Melhan. Also a plant called Kniphofia sumarae is found near Ibb, at an altitude of more than 2800 meters. It is the only extra-African species of this largely South African genus. The region is also the home of Helichrysum arwae, which the closest relative is found in South African Drakensburg Mountain. Located near the city of Taiz in Yemen, at the far south from the study area, exists the area of Hujariyah, which is probably the richest in terms of plant diversity in the entire Arabian Peninsula. The area extends over more than 100 square kilometers, supporting about 99 species of endemic plants, in a total of 357 species in the Arabian Peninsula as a whole. This includes Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Crotalaria squamigera, Kickxia woodii,˜ Blepharispermum yemenense, and yemense Centaureał
Figure 4.8 Cenitaurothamnus plant
Over thousands of years the production of agricultural crops represented the most important economic activity for western Yemeni highlands. Crops, such as wheat, barley and sorghum were widely cultivated. Sorghum has been and is still grown as the most important cultivated crop and represents the most important genetic resources in the region (Miller, 1994). In the past this region was also an important centre for myrrh, a gum resin obtained from some Commiphora species.
The ecoregion together with Tihama region, represent one of the most important areas for endemic birds in the Arabian Peninsula. The montane juniper woodlands are the most important habitat for species such as Carduelis yemenensis, Turdus menachensis, and Parisoma buryi. These birds depend mainly on juniper berries as a source of nutrition and the juniper trees for nesting (Newton and Newton, 1996).
The dramatic cliff faces on the escarpment rim are considered the habitat for large raptors such as Gyps fulvus, Aquila verreauxii and Falco pelegrinoides.
Figure 4.9 and 4.10 Carduelis Yemenensis, Turdus Menachensis Birds respectively
Its geographical location in the Arabian Peninsula makes the ecoregion a bridge between the African and Asian continents. Therefore, the areas of the Asir Mountains and the Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
western Yemeni highlands are considered as an important resting and feeding spot for flocks of migratory birds. The high escarpment and cliffs are of particular importance especially during autumn for the migrating raptors, for more than 3000 migratory birds pass by the area. (Evans, 1994).
There are also many species in the region including large mammals, such as the Arabian leopard (Panthera pardus ssp. Nimr). It is one of the endangered species of the region where its existing number is believed to be about 50 animals (Nader, 1996). The leopards exist specifically at highlands of south-west Yemen, being subject to severe environmental stress caused by overhunting.
Figure 4.11 Ocelot Figure 4.12 Spears (Running) Monkey
The Papio hamadryas is prevalent at various areas in Yemen; it is one of the species which is significantly decreasing in number in Yemen as a result of the environmental pressures, as well as hunting and killing by humans. The Caracal caracal ssp. Schmitzi is also available although it is not frequently observed as a result of hunting by the local farmers. In addition to that the Arabian leopard (Canis lupus ssp. arabs) is at risk of extinction as a result of overhunting and mating with stray dogs. Also the Hyaena hyaena is prevailing in the area, in addition to Procavia capensis ssp. Jayakari, which is relatively decreasing in number at the moment.
4.1.3.3 Risks and Threats Facing the Region
The problem of soil erosion is considered as the most important threat to biodiversity in the region. It adds to the random excess cutting of timber and fuel wood, and overgrazing of sheep, goats, cattle and camels. Miller explained (1996) how the migration to oil-rich states and the migration of villagers to the cities have caused neglect to the originally weak system of agricultural terraces. This resulted in soil erosion due to powerful rainfall Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
and lack of vegetation soil cover. The over cutting of timber trees for firewood and coal, in forest areas in mountains escarpments, has caused extreme environmental stress leading to the deterioration of the forest condition and the dramatic decrease in the number of trees. The demand for coal has doubled in the past twenty years due to population growth and the rise in income level causing alarming complications of the problem. This is despite the fact of the increase use of butane, as shown in a recent study carried out by the World Bank.
The use of modern methods of hunting, such as fire guns, rather than the traditional methods, has increased the number of hunted wild animals. This caused an extreme pressure leading to the threat of extinction of some species, such as the Arabian leopard. This animal has become very rare in the area. This is added to the conflict between the leopards and the farmers over sheep herds, as well as hunting of Procavia capensis ssp. jayakari, which is the most favored prey to the leopard. That scarcity of food is one of the major elements of the decrease in the leopard’s numbers. Modernization features including construction of roads at natural areas, especially mountainous, has lead to dispersion of wild species or blocking the species at certain areas as a result of the roadways. This only represents an aspect of the environmental pressures facing the wildlife in the area (Largot and Largot, 1999).
The Papio hamadryas is prevalent at various areas in Yemen; it is one of the species that is significantly decreasing in number in Yemen as a result of the environmental pressures, as well as overhunting and killing by humans. The Caracal caracal ssp. Schmitzi is also available, although it is not frequently observed as a result of hunting by the local farmers. In addition to that, the Arabian wolf (Canis lupus ssp. arabs) is at risk of extinction as a result of overhunting and hybridization with feral dogs. Also the stripped hyaena (Hyaena hyaena) is prevailing in the area, together with the rock hyrax (Procavia capensis ssp. Jayakari), which is still fairly existing, but its distribution range is fast decreasing in number.
4.1.4 Environmental Background based on the Findings of the Field Study
Based on a series of field visits for a number of health facilities during the field survey in the study area, most of these facilities were selected (either a health center or a district hospital) on a random basis. The employees of the selected facilities were not notified of these visits in advance. Some visits were conducted to some health units, despite being outside the scope of concern of the project. This was in order to make comparisons and to specify the practices of managing and handling wastes at different levels of health facilities. In general, a problem of solid waste management was observed, in almost all surveyed areas. The accompanying Yemeni team has also acknowledged that the problem Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
is not confined to the five governorates involved in the project only, but it represents a national concern.
Figure 4.13 One of the Qat Markets at 6am Showing Waste from the Previous Day
A lack, or even an absence of awareness about the seriousness of healthcare waste negative impacts, was also noted, in the vast majority of the personnel of visited facilities (Figures 4. 14, 4. 15). It can be noted that the methods of disposing of hazardous and contaminated waste, was done randomly at most types of facilities, either inside or outside the facility. The field survey team has concluded the following:
Figure 4.14 A Laboratory Basin in a Figure 4.15 Used Syringes Thrown in Health Facility (Ka’tba hospital) Sewage in a Health Facility
A. Organizational Structure: It was indicated that the organizational structure of all visited health facilities during the field survey did not include to a certain extent a special department for managing and handling healthcare waste, but only a services department. This is in addition to the non- sufficiency of the regulatory system for management and handling healthcare waste in general. It was also noted the lack of appropriate programs, guidelines, or any organized plan indicating a policy for handling and management of healthcare waste within health Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
facilities. However, the HCW management is mostly performed according to simple verbal instructions.
B. Personnel Handling Healthcare Waste:
It was noted that most of healthcare facilities (in the sample survey) depends in handling waste on ordinary cleaning workers through direct contracting or through a contracting company. It was found that these workers have no complete job description or specific tasks, in addition to the existence of a certain evel of lack of qualifications or specialized expertise. No enough training programs were conducted, neither rehabilitation courses aiming at raising awareness towards the types of waste, the proper methods for handling it without risks, means of prevention and safety, and how to avoid any damages during the process of waste collection and transportation.
C. Methods of Handling Healthcare Waste:
The current situation was studied at selected medical facilities concerning the methods of handling waste in general and healthcare waste in particular. The following was noted:
− Sorting , segregation and separation process:
It was noted that a number of the visited healthcare facilities do not perform the process of sorting, separation or segregation of waste collected from each department or section as appropriate as it should be. Rather, healthcare waste is collected indiscriminately from the source either a department or from all the facility in general (Fig 4.17). Except for needles of used EPI materials, i.e. syringes, lancets ...etc, which is collected in special boxes (Sharp Boxes) for keeping medical metal objects. This is following the approved safety measures applied by te MOPHP. The liquid waste is discharged through the public sewerage system.
Figure 4.16 Random Mixing Up of Wastes Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Process of collection and transportation:
It was noted that most types of waste were collected indiscriminately without any separation according to type. It is collected from the source in plain black plastic bags or plastic containers. in most cases wastes are collected by normal cleaning workers. they transfer it to the collection point. It remains at that special area within the facility in most cases for open burning, or storage in a semi-detached room then transported by a specialized company (case of Sanaa and Aden only). Otherwise most of it is thrown on the side of the road (as in the case of healthcare center of Walan in Belad Ar’Russ region and in almost all visited facilities).
Safety and prevention methods:
It was noted that the majority of personnel handling healthcare waste at health facilities included in the survey sample did not follow enough prevention or safety procedures such as using means of sterilization, protection gloves, masks and insulation clothes. However, the handling of the EPI materials following the safety measures approved and applied by the MOPHP (including sharp boxes…etc) was found followed in almost all visited facilities. It was also noted that the inhabitants of the areas were also subject to some risks, as a result of being exposed to healthcare waste which may cause physical and medical hazards especially to children and elderly. (Fig 4.18)
Fig 4.17 Accessibility and Exposure of HCW to Children
Basic storage (temporary) of waste:˜
The lack of special sites or designated disposal areas equipped with the required safety measures for waste collection was noted. Waste is collected in plastic bags or plastic containers, then transferred if any, as in the case of Sanaa the capital, by the clean-up project to dump site of Alazrakin and the case of Aden, which has a dumpsite. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Concerning the other four governorates, there is no proper sanitary landfills to handle this type waste.
Discharge and final waste processing:
Concerning Sanaa governorate, after the transfer of waste to the dump site of Alazarkin in a collective non discriminated manner, it was noted that wastes are buried under soil layers.
Health facilities in other provinces as well as in the rest of the facilities of Sanaa and Aden governorates, dispose indiscriminately of wastes. This is performed in most cases, either through open burning or by using a primitive medical incineration (Figure 4. 19). Another option is the random dumping in the open environment, whether inside or outside the medical facility.
Fig 4.18 Primitive Incinerator at a Health Facility
Operating expenses for health wastes:
Interviews with officials at the Ministry of Public Health˜ and Population; and Health Facilities, have indicated that allocations for waste management at health facilities are in numerous cases directed to other aspects related to services in general and not necessarily of waste services. Expenses in the area of waste are limited to covering the salaries of Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
workers and operating expenses. Some of the facilities have also explained that the budgets are not sufficient to implement an elaborate system of waste management.
− Health and environmental impacts of the used methods for collecting and discharge of wastes:
Based on the insufficient level of awareness of the workers on the importance of safe segregation, collection and disposal of healthcare waste; and in addition to the lack of the necessary financial and human resources to provide the required methods of prevention and safety in handling waste; field observation has concluded that the most serious negative consequences to the current situation is the impact on human health inside or outside the facility. This adds to other risks such as injuries, skin scratching and infection. Also the primary processing methods such as (land fill or open burning) has a direct impact on the neighboring agriculture areas as a result of waste decay or leakage and infiltration to groundwater.
All these environmental negative impacts caused by healthcare waste will be discussed in the next chapter. Some of the necessary procedures for mitigation will also be indicated and explained.
− Composition of HCW
Based on previous studies and on field observations, it has been noticed that healthcare facilities are producing a number of different types of wastes. The most commonly identified wastes are Municipal waste; and Healthcare waste.
As regards Municipal Wastes, it included all non healthcare wastes. On the other hand, healthcare wastes include infections wastes, sharp tools wastes, pressurized and pharmaceutical wastes, and chemical and radioactive wastes.
Based on observation of the visited facilities and on previous studies the following has been concluded. In Sana’a city a study on a number of chosen health facilities has been carried out. This study showed that the number of all healthcare facilities in the city of Sana’a were almost 120. This included private and public healthcare facilities. Municipal waste generated from the healthcare facilities in Sana’a city represents 71% of the total waste generated, while Healthcare waste (hazardous) represents 29%. Total average of daily generation of waste in general amounted 1178.77 kg/day, whereas 8018.34 kg/day were of general non hazardous waste; and 3300.49 kg/day of hazardous healthcare waste.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
As concerns liquid hazardous waste, no adequate segregation of Hazardous liquid waste from normal sewerage system was observed. The conditions in which most of healthcare facilities sewerage were, indicates that a great effort needs to be done in this area.
− Health and Safety issues related to drug and equipment delivery
Field observation showed that the conditions in which drugs and equipments are handled needs more attention and control. In some of the visited facilities, some unsafe storage conditions might occur putting a risk on drugs stored in the facilities.
As for equipments, it has been noted that almost all healthcare facilities visited by the field team were experiencing problems in operating and maintaining their equipments. Let alone the lack of equipment. This included dental clinic equipment, X-ray equipment and many others. In some cases new equipment were seen stored in very bad conditions for long time unused for the lack of operating technicians. Nonetheless, the lack of maintenance has put a number of equipment in many healthcare facilities out of order.
Subsequently a number of impacts occurred. This included the unsafe conditions for users of equipments. In addition to that the inappropriate conditions of storage and handling of drugs and chemicals could negatively impact patent’s health. The inefficiency of drugs and equipments resulting from the aforementioned conditions creates an unsafe environment for both patients receiving healthcare service and technicians/practitioners using the equipments in healthcare facilities.
4.2 Socio-economic Background
4.2.1 General Background Information on the Socio-economic Conditions in Yemen
The Republic of Yemen (RoY) population reaches around 23,208,000 inhabitants spreading over 21 Governorates that encompass 334 districts. The Republic of Yemen is characterized by the dominance of the rural characteristic where more than 70% of the population belongs to rural areas. The Republic of Yemen is witnessing modernization of the economic and political system, which resulted in the achievement of economic progress in the past few years. In spite of this, the general indicators of human development in Yemen are still low, putting Yemen to rank 153 out of 177 countries in the Human Development Report 2007/2008. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Table 4.1 Distribution of the Population According to Urban/Rural Distribution and Gender Conditions - 2004 census Urban Rural Total Gender Number ˚ Number ˚ Number ˚ Men˜ ž− ł ž ž −žž − Women˜ žž ł ž ž ž ž Total −žž − ž ž −žž 19685161 −žž Source: Central Statistics Organization (CSO), 2004 census Yemeni household income survey in 1998 indicated that about 42 of the population live under the poverty line15, while the Poverty Assessment Report 2007 indicted that the percentage of poverty is 34.8%. General poverty among population reaches up to 35% of the population, while about 16% of the population suffer from food poverty16. Food poverty is threatening about 22% of households in Yemen. Children are the main victims of this type of poverty. They suffer from various consequences, in particular malnutrition. The majority of children under five are underweight, representing 45% of this segment. The rate of illiteracy in the Republic is about 54.1% (29.6% for males, 61.6% for females) illiteracy and the low level of education along with poverty are closely related to the decreased levels of awareness in issues related to mother and child health and reproductive health.
The tough geographical and terrain features in RoY increase the difficulty of population’s access to various services, especially health services and education. The rural population is scattered in around 113 thousand gatherings/villages, making the provision of services, especially healthcare and other facilities such as potable water and sanitation a very challenging task.
Table 4.2 Important Socioeconomic and Population Indicators in Yemen Indicator Value Population in 2009˜ 23,208,000 Expected population 2015 žžž Percentage of rural population 2009 −˚ Percentage of poverty 2007 ˚ ł GDP per capita 2008˜ ˜ US$ Illiteracy among males 2004˜ ˚ ł Illiteracy among females 2004˜ ˚ žł Provision of electricity 2004˜ ˚ ł Access to potable water 2008 −˚ Access to sewage 2008 ˚ Source: Population estimates 2009 – Poverty Assessment Report 2007 The distribution of the population in Yemen is characterized by wide disparities both between urban and rural areas and among the different governorates. Around 43% of the
15 Millennium Development Goals, Needs Assessment Report 2005 16 National Health Strategy 2009-2015 Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
population RoY is concentrated in four governorates, Taiz, Ibb, Sana’a and Hodeidah. In general there is a clear migration movement from rural to urban areas. The Ibb, Sana’a and Reimah are from the expelling provinces, this may be mainly since agriculture is the main activity in these governorates. Agriculture currently faces a major challenge which is largely linked to lack of rain fall17. Sana’a, the capital, is characterized by being the most attractive spot for population all over Yemen18. This mainly returns to being the center and relatively the most favorable place in terms of availability of job opportunities and proximity to various services. Reimah governorate is the main expelling governorate according to the censuses in 1994 and 200419. This is due to the mountainous terrain of the province and the relatively limited opportunities.
Table 4.3 Families and Gender Distribution in the Target Governorates Number of families Number of individuals Governorate Males Females Total Number % Number % Number % Number % Ibb 298,085 11.16 1,158,831 11.46 1,087,245 10.93 2,246,076 11.20 Sana’a (not including Sana’a 116,276 4.35 502,409 4.97 492,337 4.95 994,747 4.96 City) Al Dahla’a 58,268 2.18 259,827 2.57 246,217 2.48 506,044 2.52
Reimah 55,072 2.06 215,268 2.13 207,314 2.08 422,582 2.11
Al Baydah 66,172 2.48 277,770 2.75 279,956 2.82 557,726 2.78
Aden 86,792 3.25 286,350 2.83 280,099 2.82 566,450 2.82
Total˜ 680,665 25.48 2,700,455 26.71 2,593,168 26.8 4,791,675 26.39 Source: Central Statistics Organization (CSO), 2004 census
As indicated in Table 4. 3 above, the project targeted governorates represent around 25 % of the population of Yemen in total, although the main share of the population is located in the governorates of Sana’a and Ibb. Some unique characteristics exist in each Governorate, especially with regards to customs, traditions, tribal style, geographical features and terrain. However, the targeted governorates are similar in many features and indicators, mainly the prevalence of the rural style consequently the presence of similar obstacles facing the inhabitants at remote rural areas in accessing health services. The similarities between the governorates of Sana’a and Reimah were observed in many aspects, especially the local customs and traditions and the geographic conditions. However, Sana’a is significantly in a favorable situation in terms of availability and access to services.
17 Meeting with responsible officials for Rima governorate. 18 Men and women in Yemen: a statistical image 2007 19 Rima is a new governorate. It was divided from the Sana’a governorate in 2004. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Table 4.4 Summary of the Topographic Conditions and Economic Activities in the Targeted Governorates
Number of Area Governorate Topographic Conditions Economic activities districts (km2) Agriculture (5.6% of the total Very rough (mountains production) mostly important interspersed with deep valleys crops and vegetables. Mining and narrow corridors pouring Ibb ž (Clay minerals used in the mostly to the west to Tihama manufacture of cement, bricks plain) and metal thermal Zeolight and basalt) Agriculture (16.2% of total production) A variety of terrain, with Mining (Zinc, silver, lead and Sana’a − −− extended mountains and volcanic substances, average height hills including Escoria and Zeolight) Agriculture: mainly coffee. Mountains, plateaus and Mining: minerals used in Al Dahla’a ž valleys, fertile plains manufacturing papers, paints, cosmetics, pesticides. Agriculture: mainly Rough terrain, high vegetables, fruits, crops and Reimah 1915 mountains coffee. Bees and production of honey Agriculture (2.6% of the total Deserts and mountain production) mainly vegetables Baydah ž − highlands, plateaus and broad and cash crops. plains of fertile land Handicrafts and traditional crafts. A coastal city which is characterized of being in front A very important and of two islands. Shamsan strategic port city which is Aden 8 750 Mountains (above 500m of regarded as the industrial and sea level) is located to the commercial capital of Yemen south of the city Total˜ Source: The National Information Center (NIC) http://www.yemen-nic.info/gover and interviews with government officials at targeted governorates
4.2.2 Economic Characteristics
Unemployment is the most critical issue facing Yemen. Unemployment rate has increased to reach 16.5% of the population over 15 years in 2007. Participants in the FGDs at target governorates highlighted unemployment as one of the most stressing problem that face youth. Also, as indicated in Table 4.4 above and Table 4.5 below, agriculture is considered one of the important economic activities at target governorates, especially in Ibb and Sana’a. Qat is the most important agricultural crop referred to by those involved in the consultation, despite its marginal representation in statistics and official data. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Table 4.5 Distribution of Employment (15 years and above) According to Economic Activity in the Targeted Governorates
Ibb Sana’a (not Al Dahla’a˜ Reimah˜ El Baydah Aden Economic Activity including Sana’a City) Number˜ ˜˚ Number ˜˚ Number ˜˚ Number ˜˚ Number ˜˚ Number ˜˚ Agriculture, Hunting, 158328 32.8 151273 63 43243 49 21593 22 24828 26.2 1,790 1 Forestry Fishing and related 0 0 0 0 0 0 0 0 259 0.27 2,930 2 activities Mining 991 0 0 0 809 1 0 0 40 0.04 1,021 1 Manufacturing 25116 5 7212 3 3012 3 2861 3 5034 5 9,007 7 Supplies Electricity, 484 0.1 953 0 118 0 0 0 205 0.22 3,736 3 Gas, Water Construction 61939 13 13553 6 5214 6 22922 24 28856 30 4,056 3
Wholesale, retail, 77275 16 9032 4 10937 12 16084 17 14060 15 24,049 20 maintenance, repair Hotels and restaurants 15575 3 466 0 1325 2 7798 8 573 1 4,154 3 Transportation, Storage 28192 6 9621 4 3634 4 2444 3 3660 4 13,219 11 and Communications Stock market 449 0 0 0 35 0 0 0 291 0 1,154 1 Real estate, leasing, 746 0 873 0 502 1 447 0 554 1 1,652 1 commercial Public administration, security, social 62020 13 29008 12 11226 13 9917 10 5528 6 29,699 24 solidarity Education 22714 5 5441 2 2905 3 3997 4 3877 4 14,850 12
Health and social work 3328 1 1421 1 427 0 2114 2 612 1 5,007 4 Personal and social 6844 1 897 0 1153 1 1220 1 1018 1 3,691 3 services Private families, 1741 0 817 0 37 0 591 1 885 1 1,269 1 households NGO’s 0 0 0 0 0 0 0 0 0 0 116 0 Unidentified 16424 3 10,400 4 3332 4 4797 5 4611 5 1,705 1 Total 482166 100 240966 100 87910 100 21593 100 94891 100 123,105 100
Source: Central Statistics Organization (CSO), 2004 census
4.2.2.1 Poverty Level in Targeted Governorates:
It is difficult to formulate a precise definition of poverty. It is also difficult to limit the concept of poverty to low income or lack of access to services. With the increasing amount of UN literature and studies that assess the phenomenon of poverty and develop diverse definitions for it, it is becoming increasingly important to consider a more comprehensive concepts that encompasses the different dimensions of lack of income, lack of production resources sufficient to ensure the livelihoods, persistent hunger or malnutrition, poor health and limited access to education and other basic services along with non tangible dimensions like marginalization from the decision-making process and deprivation from the civil, social and cultural rights. The Poverty Assessment Report issued by the United Nations has indicated a broader concept to poverty and this concept Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
was employed to develop a ranking for the Yemeni Governorates as indicated in Figure 4. 20.
Figure 4.20 indicated that four out of the six targeted governorates include poverty rate of about 25% to 35%, with the exception of Al Baydah governorate where the poverty rate reaches 50% to 60%. It is necessary to indicate here that the percentage of poor population at governorates of Sana’a, Al Dahla’a, Ibb and Reimah still represent a large portion. This category is usually concentrated in rural areas which suffers more from the indicators related to the poor quality services as well as economic poverty
Fig 4.19: Percentage of the poor by Governorate 2005 – 2006 Source: Poverty Assessment Report – UNDP 2007
4.2.3 Education
The education status in Yemen, has witnessed a significant progress compared to the situation several years ago, where the illiteracy rate among Yemenis was one of the highest percentages among Arab and developing countries. Table 4.6 clearly shows that a quantum leap between year 1991 until 2005 due to the increase of enrollment rate in basic education from 51% to 66%. It is noticeable also that the increase in enrollment is more indicative in females, witnessing a wide progress to grow from 28% in 1991 to 66% in 2005. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Table 4.6 Average Enrollment to Education (ages 6-14) from 1991-2005 Year Males% Females % Total% 2005 74.7 55.3 65.5 2004 70.3 54 62.5 1999 73.6 45 59.3 1998 75.3 41.7 58.2 1994 70.3 38.5 55.2 1991 73 27.6 50.9 Source: Central Statistics Organization (CSO , 2004 census
It can also be noted from the same indicator on the level of the project target governorates from table 4.7, that the highest rate of enrollment was in Sana’a Amanna. This is an expected indictor that is due to the increased level of awareness and the enhanced provision of educational services. The contrary could be observed by looking at the situation in the governorate of Sana’a, which showed a significant decrease in the number of enrollment, especially among females. The inequality between male and female enrollment percentage is clearly shown in all the governorates, especially in the governorate of Al Dahla’a, with the only exception of Sana’a Amanna.
Table 4.7 School Enrollment Percentage (age 6-14) in the Targeted Governorates 2004 ˜Governorate Males% Females % Total% Ibb 75.7 57.9 67.0 Sana’a (not including Sana’a 75.7 50.5 63.5 City) El Baydah 68.5 51.2 60.3 Al Dahla’a 97.1 62.9 71.3 Reimah 67.5 41.6 55.0 Aden 78.5 76.2 77.4 Source: Central Statistics Organization (CSO) , 2004 census
Despite of the importance of the indicator of enrollment to basic education, it could not be treated as an indication for educational achievements. In several cases enrolled boys and girls drop out of school without completion of any educational stage. This situation is very frequent among females. Table 4.8 indicate the distribution of population according to educational level, gender and place of residence (urban or rural) in the Republic due to the lack of this data in target governorates. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Table 4.8 Educational Status of Yemen Population by Urban/ Rural Residence and Gender
Urban Rural Level of Education Males Females Total Males Females Total Illiterate ˜ − ł ł ł ł −ł łž Read and write ł ł ł ł .− žł Primary ˜ ł ł ł ł −łž ł Basic/ preparatory ˜ − ł −žł − ł −žł ł ł Diploma pre −łž žł žł žł žłž žł secondary˜ Secondary or − ł −žł − ł ł −ł ł equivalent Diploma after ł −ł− −ł −ł žł− žł secondary University or łž ł ł −ł žł− −łž higher˜ Not indicated ˜ žł žł žł žł žł žł Total˜ −žž −žž −žž −žž −žž −žž Source: Central Statistics Organization (CSO) – Population Demographics 2004
Despite the difficulty of generalizing educational indicators of the Republic to the five target governorates, it is still possible to derive some general indicators, which can be claimed as applicable to the case of the target governorates, these indicators can be summarized as follows:
ƒ The highest percentage at urban population could be classified as literate/can read and write. However, for the rural areas illiterate is the most dominant educational classification.
ƒ The portion of population classified as illiterate is significantly high in rural area compared to urban areas.
ƒ Gender gap among the illiterate segment of population is quite clear in both rural and urban areas with females representing the higher percentage of illiterate.
ƒ The segment of university graduates is limited in both rural and urban areas but more obviously limited in rural areas.
4.2.4 Gender Issues
HPP is closely related to issues of gender, since it targets women, in the first place. The general situation of Yemeni women’s access to health services is seen to be strongly related to their access to social and civic rights. As will be explained in the different cultural, geographic and economic backgrounds of the ESIA, several considerations are dominating and largely affect the overall situation of women and limit the mobilization capacities of women in access to information and decision-making. This will be explained in detail later in the ESIA. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
The general situation of women still reflects many restrictions imposed by society, out of the notion that girls should remain "under protection" and the concept that the external world represents a danger to girls and that girl’s reputation is strongly linked to the reputation of the family / tribe. However, the culture that puts women "under protection" usually limits women’s abilities and challenges their access to fair opportunities to success in life. Protection in most households, especially in villages, means marriage as soon as the girl reaches teen aging. "Perceptions and Realities: Yemeni Men and Women, and Contraception"20 that the average age of marriage among girls is 17 years and among men is 22 years, among the current generation of the newly-wed couples. Older women (ages over forty) were married, mostly at ages ranging from 13 to 17 years. This finding is consistent to a large extent with the results of the field study conducted during preparation of the ESIA. Separate interviews were conducted for women ages 20:35 and for women over forty. It was clear from these interviews that the age of marriage among women has relatively increased among the first category, but that it is still significantly low ranging between 17:19 years.
In most of cases, early marriage is the beginning of a series of troubles for women. First of all it is the end of their education and consequently an end to the potential of their participation in practical life. The lower the educational level of a girl, the lower her level of awareness and her participation in decision-making in the future. Marriage is often accompanied by significant pressures on women health, especially at rural communities with decreased level of provision and access to services, where poverty prevails and the level of nutrition is deteriorating. The next part of the study presents some educational and economic indicators of relevance to women
4.2.4.1 Economic Participation among Women
Results of previous reports and results of the field interviews indicated the genuine participation of women at various activities and jobs inside and outside of the house. Women also play an important economic role. However, this is usually performed on an informal basis, thus the economic role of women in Yemen is often marginalized and invisible since it is not indicated in official statistics and also because most of the activities that women practice are the traditional ones such as agriculture. These activities are strongly characterized by being marginal and insecure in terms of income. The most important reasons for women’s involvement in such activities is the high rate of illiteracy and the inability of women to break into better opportunities in the labor market due to customs, traditions, and culture, especially in rural communities. In addition to the decreased level of awareness and the absence of active NGOs that target women. In
20 A report produced by Marie Stopes International and the German Development Bank (KFW), April 2008 Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
general, women who had a share of education are relatively active in very specific sectors, especially education and health. This is in particular applicable to districts, and not in villages and isolated areas21.
Interviewed midwives and health workers indicated, during the visit to health facilities, that they usually use the messages linked to the ability of women to work in order to convince women of the importance of spacing between pregnancies, and especially that there are many areas where agriculture comes under the tasks that are dedicated only to women22.
The interviewed officials at El Baydah province stated that women usually maintain and engage in the household based business and economic professions like sewing, handicrafts, women decorations, dressmaking, manufacture of incense and basket-making and some household items from palm fronds. As a result of customs and traditions women do not work in the markets in most governorates, but women cooperate with their husbands in agricultural activities in rural areas, raising cattle and sheep grazing. Also, some tasks such as fetching water from are done by women and only children help in these tasks.
The case of women participation in economic activities outside home in Aden is considered as an exceptional case where significant portion of women are engaged in industrial establishment, governmental offices and NGOs23.
4.2.4.2 Women and Education
A relative disparity was noticed in the status of education and employment of women at target governorates and this has clearly reflected on some concepts and practices that have been measured. As shown in Table 4.9, Reimah represents the highest illiteracy rate among women in all governorates, while the proportion of illiterate women is less obvious in Sana’a Amanna and in Aden where more interest in girls’ education appears.
21 Governmental Official in Reimah Governorate. 22 Interview with health providers in Wa’lan hospital in the country of Ros – Sana'a 23 Women Role in Local Economic in Aden, Yemen, World Bank, 2005
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Table 4.9 Percentage of Illiterate by Gender (more than 10 years) in the Targeted Governorates 2004 Governorate Male ˜Female Ibb ł žł Sana’a (not including ł žł Sana’a City) Baydah ł žł Al Dahla’a žłž −ł Reimah ł ł Aden 13.2 ł Source: Central Statistics Organization (CSO) – Final report 2004 Census Most of the interviewed participants related the decline in women educational status in the targeted governorates, to the perception of women as a pillar of the house. This perspective loads women and girls with several household based and external burdens/ responsibilities. These burdens/responsibilities are the main reason from the girls early drop out from schools without accomplishing any educational level.
Concerning the educational status of interviewed women in the study, a considerable and clear disparity in women educational status based on age was observed. Most interviewed women over the age of forty were illiterate, with the exception of the governorate of Ibb. The ratio was 2 women with primary certificate holders versus 6 illiterates in the indicated age group. As for the newlywed, they had varied educational backgrounds and the majority had finished middle and high school. This is an indication of the high level of awareness of the importance of educating girls. It is worth mentioning that this has been reflected clearly in the views of the participating women in issues related to MNCH, as will be discussed later.
4.2.5 Health Indicators Related to the Project
Non-satisfactory health and population indicators are the most important challenges facing RoY in its adoption to the Third Development Plan for Poverty Reduction 2006- 2010, which is part of the framework of the Millennium Development Goals (MDGs). On the level of health achievements, Yemen has achieved a remarkable success in certain indicators like life expectancy at birth, which increased from 57.3 to 61.5 in the years 1994 to 2008, respectively. The State has given special attention to the health sector through providing support funding24, encouraging decentralization, and local, community
24 Health sector expenditure reached 3% in 1997 from the total expenditure and 1.2% from GDP, compared to 3.38% from the total expenditure and 1.21% of the GDP in 2007. The share of the individual from the Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
and private sector initiatives. Yemen also succeeded in reducing the rate of infection of malaria, in addition to the success of campaigns against tuberculosis, polio, as well as the decline in infection with measles, diarrhea, and thus decreasing mortality rate among children.
The percentage of infants who have been vaccinated with Penta 3/Polio 3 was 87% in the years 2007, 2008 and 2009 compared with 66% in the year 2003. Fertility rates relatively decreased due to the awareness and use of family planning methods, where the percentage of users in 2005 reached 41% compared to 6.1% in 199225.
In general, the interviewed governmental and NGOs stakeholders, as well as community members, during the preparation of ESIA, expressed many positive aspects concerning mother and child issues. The most positive improvement was the increase in the level of community awareness of these issues especially concerning the procedures related to child health and immunizations. This was reflected in the significant reduced incidences of many diseases such as measles and, polio. Yemen has recorded a success story concerning the control of measles, which dropped from 30,000 cases annually with 5,000 estimated deaths to 13 lab confirmed cases in 2009 with no deaths since 2007 26.
Stakeholders also expressed their observations about the increase in community awareness with regard to population issues, such as family planning and reproductive health, as a result of the growing media interest on one hand in addition to the role played of health facilities in raising awareness in some areas27. This awareness increases the realization of the importance of follow-up care during pregnancy and access to immunization. The interviews findings with different age groups women28 indicated the increase in the awareness level and change in concepts among women from the new generations.
"Yes, we used to see death and nobody helped us, we gave birth to 10 children most of them died"
Mothers-in-law Interview – Azlet el Arees District of Beni Matar – Sana'a
total expenditure increased from 608 YR in 1997 to 2430 R in 2007. However, this increase is perceived to be superficial because no equivalent increased has occurred to the value of YR against the USD. 25 National Information Center (NIC), http://www.yemen-nic.net/contents/Health/ 26 Hackman, Alice, "Reducing neonatal tetanus and measles mortality by 2015," Yemen Times, 12/08/2009, http://www.yementimes.com/DefaultDET.aspx?i=1230&p=health&a=1 and information from Family Health Department, MoPHP 27 Sofleya Directorate – Rima governorate 28 Field meetings included 3 groups of women representing three generations (newlyweds, women 40 years old, and mothers in law) Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
"Change was that we knew that spacing and not controlling the children number is better for the health of the mother, and we can raise the children in a better way, we make use of these methods especially educated women, Although in some cases husbands are reluctant to accept the idea of family planning " Newly wedded women – Gabla District– Ibb Governorate
Yemen is still facing significant challenges in the field of women and children’s health and infectious diseases. The rate of population growth is 3.02% and the fertility rate in Yemen reaches 6.2 children per woman, which is one of the highest rates in the world. Statistics point also to the large family size ranging from 7-8.5 persons / family in target governorates. This, in turn, indicates the health and physical burdens encountered by families, especially within the challenging conditions of poverty and the consequent difficulty of providing adequate health care for the mother and child. Yemen also has one of the highest rates in the world of maternal mortality at pregnancy and birth, where mortality rates reach up to 365 maternal deaths per 100,000 live births.
Table 4.10 Average Family Size at Targeted Governorates (1994 and 2004) Year Governorate − žž Ibb ł łž San’aa (not including Sana’a ł ł City) El Baydah łž ł Al Dahla’a łž ł Reimah ł− łž Aden 6.2 ł Source: Central Statistics Organization (CSO) – Final report 2004 census
The above table 4.10 indicates the increase in the average size of families between years 1994 and 2004, that all target governorates have witnessed. This contradicts stakeholders’ observations that family planning programs are booming and are relatively more accepted than in the past. The data above can be, however, justified with the following explanations:
ƒ Governmental, donors and NGO’s programs of relevance to the project stated to witness significant increase since 2004. Thus measurement of these indicators in the following years is expected to reflect improvement.
ƒ Family planning is promoted in Yemen through the concept of spacing rather than birth control (controlling the number of children). Thus the average family size can be stable or can witness a slight up or down variance. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
ƒ The increase in average life expectancy as a result in the improvement of health services.
ƒ The figures could probably be affected by other forms of population growth like the external and internal migration.
ƒ Indicators may also suggest that a large number of families (specially at rural area) are not interested in family planning.
"I swear I’ve never used a contraceptive and I don’t know anything about them? Since the day I was married I get pregnant and give birth, God is gracious – life and death are only determined by God" A 45 year old lady, mother of 13 child - Azlet el Arees District of Beni Matar – San'aa
These indicators reflect lagging behind in mother and child health status, which represents a major challenge on the path of Yemen development and in achieving the MDGs, especially the fourth and fifth objectives, related to reducing the rate of child mortality and improving maternal health.
The Poverty Assessment Report prepared by UNDP in 2007 presented the findings of an in-depth field study conducted by the World Bank29. It clearly indicated that members of the community in general are dissatisfied with the quality of health services provided. The report highlighted the problems of provision of health services especially that is received by the poorest segment of the community, due to their inability to afford the associated cost of transportation to access the health facility and also due to their inability to afford the private sector services. Women, in particular, suffer more from these conditions due to the additional restrictions imposed on their mobility as indicated later.
It is worth noting that about 77% of deliveries are conducted at home and that less than 30% of the cases attended by a qualified medical cadre. Prior child delivery, only 13% of the cases whose deliveries have been attended by a qualified cadre receives pre natal medical supervision. It should also be noted that about 48% of births are conducted by relatives (grandmother), or neighbors. There is usually the risk of lack of sufficient knowledge about the proper procedures for handling risks during birth. Moreover, the health facilities locations in places far from the villages in most of the cases, makes it impossible to refer the cases or intervene in critical situations. What makes that situation even more challenging is that fact the health facilities in the majority of cases are not equipped for receiving such cases30.
29 Quantitative evaluation for available health programs based on community participation: 5 programs and 6 locations in Yemen – The World Bank 30 A detailed summary of the Millennium development goals related to health: Common Country Evaluation for Yemen, 2005. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
"We do not have the necessary human resources or equipment to receive a case of complicated delivery " Health Officer in Zafir health unit – Beni Matar District– Sana'a
˘If labor becomes difficult we wait and be patient till God makes it easy – there is no one to help with the birth except the health worker and she cannot do that˘ Newly wedded women at Arees village – Beni Matar District– Sana'a Maternal mortality during delivery represents about 33% of the total cases among women under the age of twenty-five. It increases to about 37% of the total cases among mothers with frequent births (5 or more births)31. The rates of mortality during pregnancy are about 18% of the mortality cases. Mortality during delivery or shortly in the pre natal period increases to about 82% of the total mortality cases. The percentage of pregnant women immunized against tetanus in 2006 was 20%32. This rate is very limited, especially with the fact that about 77% of births occur at home under unsafe and very vulnerable and unhealthy conditions.
Through reviewing indicators related to child’s health, it is clear that despite the decline in child mortality rate for children under five years by half since 1990, further efforts are still required to address this indicator which is linked to MDG 4 that aims at reducing child mortality rate by two thirds between 1990 and 2015. Despite the exerted efforts, Yemen is still one of five Arab countries with a very limited progress in this field33. In addition to that the rate of infections related to environmental deterioration and the lack of environmental services (water, sewerage and solid waste management) is still high, women and children are often more likely to bear the cost of these types of diseases.
Table 4.11 Indicators Related to MNCH in Yemen Indicator Value Fertility rate (children per woman) 6.2 Mortality rate among pregnant women˜ /100000 % of women receiving after birth medical care˜ % of births conducted under medical supervision % of usage of family planning methods˜ 13.4 New born˜mortality 37 ˜/−žžž live births Infant mortality rate (IMR)˜ 74.8 ˜/−žžž live births % of the spread of diarrhea ˜ ž % of decline in child weight˜ Vaccination Coverage ˜(2007-2009) 87 Source: Millennium Development Goals – Needs Assessment Report, 2005 and Family Health Department, 2010
31 A detailed summary of the Millennium development goals related to health: Common Country Evaluation for Yemen, 2005. 32 National Information Center (NIC). http://www.yemen-nic.net/contents/Health/ 33 The development goals report "Between Hopes and Achievements" has indicated that Somalia, Mauritania, Djibouti, Iraq, Sudan and Yemen are the least likely countries to achieve MDG 4 by the year 2015., http://www.un.org/arabic/esa/rbas/MDGŽ Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
4.2.6 The Main Causes of MNCH Problems
Based on the analysis of the health indicators related to the project, and based on the consultation meetings conducted during the preparation of the ESIA, it was indicated that there are a number of challenges facing mother and child health sector in Yemen, which largely applies to the targeted governorates. Despite the diversity and complexity of these challenges and their connection with several other backgrounds, the ESIA attempted to divide the challenges into: 1) challenges of geography and terrain, 2) culture and community challenges, 3) institutional challenges and, 4) funding challenges.
1. Geography and Terrain Challenges
Yemen is characterized by great diversity in surface features. It is also characterized by mountainous areas of high altitude reaching 3000 m above sea level especially in some governorates like Sana’a, Ibb and Al Bayda. In addition to that, population dispersion is a unique feature of the Yemeni Governorates, especially at rural areas where small scattered groups live in remote locations, away from the location of health services.˜This makes the process of provision of services economically unfeasible and prevents the Government from providing health services equitably to everyone. Some reports indicated that the percentage of the rural population who live in close proximity to health facilities do not exceed 30% of the total rural population34. As indicated from the information of the HRSP the percentage of population in the third zone 35 is almost double the percentage of population living at first and second zones36. The situation is worsened by the lack of public or private means of transportation. Since most of the rural population is relatively poor, the accessibility to the service - at first place – is a great burden, especially for women and children, and in particular cases of the absence of men, and also in critical situations, where the time factor is crucial like the case of complicated births.
˘ Delivery outside the house is tiresome since the hospital are very far and no car is available. There is also no money to rent a car˘ A midwife in Wa’lan Rural Hospital – Sana'a
A significant percentage of health facilities conduct a zoning map to the areas and record the percentage of cases that they serve from the different service zones. It was noted that in most of the cases, the percentage of recipients of the service in the second region did not exceed 10% of the total beneficiaries of the health facility. This emphasizes the
34 Social analysis for Yemen, 2006. 35 Areas located more than one hour away from the health facility. 36 The first zone area is the area of the health facility, the second is 30-60 min. of walking to the health facility. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
importance of the outreach service, which is the core of the HPP, in tackling the accessibility challenge.
Fig 4.20 A map for the outreach zoning, Orayeb Fig 4.21 A Graph Representing the Health Centre, Makiras District, Baydah Percentage of Visitors the Health Center Governorate from Different Zones, Mohamed El Dora Hospital, Gahana, Sana’a
2. Cultural and Social Challenges
This type of challenges was clearly spelled out during the interviews with different community categories. Local Yemeni culture, especially in rural areas, poses many restrictions on the mobility of women. These restrictions are also applicable to the cases when a woman is in need of health service. The literature review findings accords to a very far extent with what have been indicated in the field interviews.
1. Popular Misconceptions
Some misconceptions prevail in the visited communities, which are incompatible with scientific backgrounds. These beliefs are used by community members to create their own interpretations. Some examples of these popular interpretations is in the situations when a woman dies during delivery because the placenta did not come out. Local communities interpret this as "Al Akra", which is believed to be an animal that enters the women’s womb and causes the woman to bleed to death. Similarly many of the beliefs are related to using contraceptives, such as the perception between the reduced level of fertility and the use of contraceptives. There is also the link between contraceptive and clots, neurological and psychiatric diseases37. Some also refrain from vaccination of children, believing that vaccination may adversely affect the future fertility of the child. There are also more prevalent beliefs that vaccination against tetanus during pregnancy may harm the fetus, and the woman.
37 Health providers meeting, Mohamed El Dora Hospital, Gahana directorate Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
2. Preference for Male Siblings
There is a dominant discrimination culture that promotes for preferring the son for the daughter. Sons are perceived to support to their father’s and it is said that "the son is on the head". The results of some interviews38 and studies indicated that women who give birth to boys are usually respected by their husband’s family and community. This culture in most of the times causes disruption to family planning programs and at the same time, it is a destructive discriminatory culture against women. This local perception should be dealt with through awareness programs.
"A woman who gave birth to girls keep having children until she gets a boy" A Local Midwife in Mohamed El Dora Hospital – Gahana District– Sana'a
3. Tribal Disputes
The field interviews indicated that some of the tribal and social disputes may hinder women’s access to health services. And in cases where there is a health facility in an area of tribal conflict, woman is obligated not to use this health facility although it may be the closest to her. This represents an obstacle to women and children from getting the right of receiving the service.
˘If there is a problem between two tribes and the health facility is available at a conflict area, the lady is not allowed to visit the center since it is located in the borders of the other tribe locality˘ A midwife in Wa’an Rural Hospital – Sana'a
4. Woman’s Role in Decision Making
The literature review 39, and most of the conducted interviews indicated, that the process of decision-making on the household level and all decisions related to receiving services during women’s pregnancy and delivery, as well as the decision regarding the use of family planning methods, are all men’s decisions, in first place.
"I agree to the importance of using a contraceptive, but my husband does not agree to using any!!" An Interview with a 40 years old lady in Salafeya District, Reimah governorate
It was noted that the participation of women in decision-making process varies according to region, and the level of the wife's education and culture. Most of the women who were referred to as non-participant in family planning decisions were not educated. In addition,
38 Meeting with a teacher at the health institute and a midwife trainer 39 Facts and concepts: Yemeni men and women and family planning methods, Marie Stopes’s foundation and German development bank, April 2008. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
the mothers-in-law 40 (mother of the husband) played a major role in their sons’ decision concerning birth control and the possibility of the wife’s receiving an outside health services. Previous reports indicated that the mother-in-law plays a role in convincing the husband to marry a second wife in the case that the woman did not give birth to a son or if the wife wanted to use a contraceptive41.
5. Level of Community Awareness
The level of awareness in rural communities is still low and they are still dominated by tribal culture such as in places like Reimah and Sana’a which impose many determinants and uniqueness on these communities. Thus, local communities are affected by concepts of local culture which are still controlling the situation. Concern for women's privacy is the determinant behind the decision for choosing to deliver at home, regardless of the risks related to this situation. Even in the case of an emergency during delivery, women are not allowed to go out if the husband is absent. This poses a big threat to women lives and in several cases, is the main reason for maternal mortality. In addition, many members of the community still agree with the view that family planning is forbidden from the religious point of view. Forty percent of the Social Marketing Survey sample pointed to this perception42. "The house costs less and it is more safe, private and convenient" Mother-in-law Interview – Arees village – Beni Matar District– Sana'a governorate Promotion of family planning services is still weak and almost non-existent in a number of areas that lack health facilities and broadcast media. The service recipient women who were interviewed during the preparation of the ESIA, pointed out that the television for women, and radio and newspapers for men are the most effective methods for delivering awareness messages. Meanwhile, a group of service providers indicated that verbal, face- to-face communication or these tools supported by illustrative methods are the most effective43 and convincing to the recipient, especially when the communicator of the message is a local, respected figure44.
In some health facilities there is a special room for health education45. In these rooms awareness messages are promoted on a case-by-case basis (example: child nutrition in cases of diarrhea, raising women’s awareness about family planning, awareness of the
40 The mother in law is called aunt. 41 Facts and concepts: Yemeni men and women and family planning methods, Marie Stopes foundation and German development bank, April 2008. 42 Meeting with the manager of the national center for health and population awareness. 43 A health guide in Wa’lan rural hospital – Sana'a 44 The national center for health and population awareness 45 For Example – Mohamed El Dora hospital in Gahana directorate – Sana'a. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
importance of pregnancy follow-up visits). A variety of visual and vocal aids are used to assist in the delivery of these messages. The most important of these aids are illustrations, oral messages and video tapes shown to the attendees. A trained midwife usually provides services in this room. However, this service exists in a limited number of facilities.
Figure 4.22 and 4.23 Health Education Room, Mohamed El Dora Hospital, Gahana, Sana’a
The level of awareness in Governorates with relatively better human development indicators as shown above was observed to be much higher and local communities are using the fixed health facilities in higher frequency that the other governorates46.
6. Chewing Qat
The results of the Yemen Family Health Survey, 2003 indicated that the percentage of chewing Qat among the survey sample (the sample targeted population above 10 years old in rural and urban areas) reached 42%. It was clear from the results of the survey that men, especially in rural areas are more inclined to chewing Qat than women. It was also indicated that the age group from 10 to 20 years, is the least likely to use Qat. Excluding the age group from 10 to 20 years, the survey results can be summarized in Figure 4.25.
46 Dr. Nadia Saad Kaid, Head of the Reproductive Department – Aden Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Figure 4.24 – Percentage of Consumption of Qat among the Sample of the Family Health Survey
Percenage of Chewing Qat By Gender and Age Group
70 60 50 40 Male 30 Female 20 10 0 20- 29 30-39 40-49 50-59 Age Group
Source: Family Health Surveyà Yemeni women, until recently, were not allowed by the family to use Qat since it was socially inappropriate for women. With the introduction of modern life, chewing Qat has become widespread among women, and women now have their own Qat sessions47 similar to men. The results of the field visits and the interviews with stakeholders showed some differences from the Family Health Survey. Since midwives and health workers noted that the Qat is one of the most important social arrangements that a large percentage48 of married women are keen to organize. It was evident from the meetings that stopping chewing Qat during pregnancy is one of the difficult things that most women cannot do. Giving up or reducing usage of Qat during pregnancy is one of the important messages that community volunteers and female health workers deliver to pregnant women49. Chewing Qat negatively affects the appetite of the pregnant woman and consequently reduces the amount of food reaching the fetus, leading to some diseases such as anemia, malnutrition and general weakness. It is, therefore, an important cause of malnutrition for the fetus and a cause of the reduction of the amount of oxygen that reaches it.
"Most of the people here work in qat, we try to make pregnant women stop using it – but it is very hard" A Health Worker at Mohamed El Dora Hospital – Gahana – San'aa
The many negative effects of Qat on the family and the children were raised during the interviews and the Public Consultation. Some poor families give priority to purchasing
47 Qat sessions for women started as a result of all free time women have since men spend a long time chewing Qat. Qat sessions are regarded as a social arrangement that allow networking and the exchange of opinions and experiences. 48 Meeting with health service providers – Mohamed El Dora hospital – Gahana directorate – Sana'a Governorate. 49 Midwife trainer and teacher at the Higher Institute for Health Affairs. Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Qat (even in times when its price is high, such as winter) instead of securing food for household consumption. This has a negative impact on children who cannot find what satisfies their need of food. The same can be applicable to other needs which may be given a lower priority than Qat (such as medicines - vitamins .... etc.)
We, Yemeni people, are spend wastefully on harmful items like qat. We suffer from behavioral poverty and not economic poverty"
Dr. Abdel WahabEl Al Ansi- Yamaan Association for Health and Social Development
7. Poverty and Lack of Services
Many of the services provided by government health facilities are free of charge, such as immunizations. In addition, some of the family planning means such as contraceptive pills are often sold at government facilities at a very low rate (250 YR). Delivery in equipped government health facilities is free of charge. But this does not actually reflect the costs that families encounter in receiving the service. Most of the time, facilities suffer from a lack of medication, are not equipped to receive emergency cases or do not have the necessary human resources. In addition, working hours are limited and the midwives do not work for free except during official hours. Outside these working hours, they charge fees50.
"Vaccination is offered for free, family planning means are sold for 250 YR, but in case of emergency traveling to Sana’a costs not less than 20000 YR. Birth is conducted at home, but in case of emergency the transportation cost exceeds 20000 YR. In addition to that most of them bleed all the way leading to complications and finally to the death of the baby." A meeting with newly wedded – Sofleya District – Reimah governorate
The National Center for Health Education and Information (NCHEI) indicated that the lack of some services such as electricity in most rural areas is one of the important challenges facing the dissemination of educational messages. It is known that the percentage of connected users to power lines at rural areas is very limited. The absence of electricity represents a multifaceted problem. Many of the existing health facilities in rural areas do not work in the evening due to the absence of electricity51. As a result, the absence of an appropriate cooling system for preserving drugs leads to the inability of receiving the necessary drugs at health facilities. On the other hand, the lack of electricity adversely affects the rural people in an indirect way affecting also their health culture. Workers involved in outreach programs in areas served by electricity were interviewed and indicated that outreach programs broadcasted on television contribute to raising awareness about various subjects, especially vaccinations and family planning.
50 The interviewed stakeholders indicated that they usually pay the midwife between 3000-8000 YR, but this is mainly done on the basis of personal initiative from the beneficiary’s family. 51 ESIA for the Rural Electricity Access Project (REAP) Yemen, 2009.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Figure 4.25 and 4.26 NCHEI Studio where awareness programs are prepared for broadcasting
4.2.7 Organizational Backgrounds Related to the Project
4.2.7.1 Governmental Sector
The general governmental health sector is one of the most important sectors that provide health services to various categories of citizens. The Ministry of Public Health and Population (MoPHP) is responsible for the provision of such government services. This is driven from the presidential decree issued in 2004 that describes the executive structure and the detailed job description of all sectors and departments of MoPHP. According to the Health Law 4 of 2009, MoPHP provides a network of government health facilities that operate at four levels as indicated in Figure 4. 29. MoPHP consists of four major sectors as shown in Figure 4.28. The Primary Health Care Sector has two General Department, the General Department of Family Health and the General Department of Diseases Control and Surveillance. The Population Sector also has the General Director of Reproductive Health and the National Centre for Health Education and Information (NCHEI). These four General Departments are seen to be strongly linked to the project. Volunteers do work with communities under the supervision of the General Department of Family Health whereas midwifes work under the supervision of the General Director of Reproductive Health.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Fig 4.27Organizational Chart of Yemen MoPHP
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
NCHEI is concerned with all issues of awareness related to population and health education, on the central or the local level, through designing policies and strategies and preparation of awareness materials including; publications and radio and television programs, according to the sectoral priorities identified by the MoPHP. NCHEI broadcasts awareness materials in 4 governmental channels, and two private satellite channels. The center also broadcast a number of programs and awareness messages through the 14 radio station. In addition to this the center is meant to conduct several outreach activities undertaken in collaboration with community leaders such as religious leaders, schools and other community institutions. The center contributes to delivering awareness messages through a variety of tools such as mobile cinema or awareness manual, which includes forty two -awareness messages. In addition to that the center coordinates with the health centers and is working with some staff at other centers, such as community volunteers whose number is about 1200 young man and woman in various provinces. Their qualifications range from high school degrees to university degrees. Youth are keen to join this work despite the low financial incentives paid to them. NCHEI Director highlighted the effective role of volunteers in the local community because of the difficulty to access to people in remote areas, which is one of the most important constraints. Since volunteers are usually local resident, this contributes to making them more familiar with the people and more influential on them.
Specialized Centers Fourth
Referral Hospitals Third
Target level of Health District Hospitals Second and Population Facility Health Units and Health First Centres
Fig 4.28 Different Targeted Levels of Governmental Health Facilities of MoPHP - Yemen
The MoPHP is represented by a Health Office located in each governorate. Within the Health office, the various departments are represented, including the Department of Reproductive Health and the Department of Family Health. These departments in Health Offices are concerned with offering family planning services on the Governorate level in addition to providing different types of support to the facilities according to each department needs. Moreover, they are concerned with monitoring services and providing training such as training of midwives and male and female community volunteers.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
NCHEI is represented in each governorate and a responsible coordinator on the level of each District
Since 1998 the ministry adopted a reform program for the health sector which focused on decentralization and supporting community participation. The primary health services and facilities, such as basic health units and centers, cover only 45% of the total population and no more than 30% of the total rural population. At the same time, there is not equitable distribution for these services since there are hundreds of under-served rural communities as a result of their remoteness and the difficulty in accessing them because of the rugged topographic conditions. Many of the existing facilities are not operating; there are 2099 health centers in Yemen although the number of operating centers is about 1700 (only about 80% of existing). Moreover, the prevailing percentage of the facilities does not receive referral cases as indicated from Figure 4.31, given the lack of the expertise in the facility to handle emergencies and serious case. Thus, the available alternatives offered to critical cases which require special care are limited and inadequate.
160
140
120
100 Hospital 80 Health Center 60 Health Unit
40
20 0 Reimah Al Baydah Ibb Al Dahla’a Sana’a Aden
Fig 4.29 Operating Health Facilities in the Targeted Governorates – Health Analyzer Program 2008
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
250
200
150 Available Not available 100 Unidentifed
50
0 Reimah Al Baydah Ibb Al Dahla’a Sana’a Aden
Fig 4.30 Number of Health Facilities with Referral Services in the Targeted Governorates - Health Analyzer Program 2008
There is no accurate inventory available about the health facilities involved in the provision of maternal and child health services, the third National Health Strategy indicated that less than 40% of the existing facilities provide the services of reproductive and child health, programs for infectious and communicable diseases, health awareness and diagnostic services. The situation can be considered as a representative of targeted governorates, which appeared during the visits to some disadvantaged areas such as in Al Dahle’a Governorate (Beni-Muslim area - the District Shuaib, Tows Shan area, Alazarq District and Beni Illian area, District of Goban, Alshernmh area - Qaataba District and in the Governorate of Al Baydah (Nata, Numan and Mosawra), in the Governorate of Al Reimah (Alosor, Al Dabara, Beni Suhail Almagharm, and Beni Ahmad Jafari), in Sana'a Wadi Har - Safan, and Hreib Naham - Naham, Bein El Hamam - Beni Dabian) and in Aden's rural districts like Bourieka as well as the other urban slums located within the cities.
The main problem is the limited resources, which affects the quality of provided services in the facilities due to the lack of several medical equipment and essential medications. The lack of resources and financial allocations adversely affect the staff working in the field of healthcare where they always feel neither well appreciated nor satisfied by the limited salaries and the absence of incentives lead to loss of staff who tend to leave the public rural facility and prefer to work in the city. Other health staff is not performing appropriately in their jobs in government facilities but rather give their private work the priority. Although the data of Yemeni health sector analysis program noted that the average number of working hours for most of primary health care facilities ranges from 5 to 6 hours a day, the interviews indicated that the units and health centers are empty most
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
of the time and the official working hours are no more than 4 hours a day52. In addition to that, the lack of qualified and trained personnel in the field of health services is one of the main problems affecting the quality of the provided services.
"If the doctor is available, the lab is not, or the medications or the equipment is missing, therefore no one visits." Health worker Wa’lan Rural Hospital – Sana'a
Rural areas suffer, like most deprived areas of Yemen, from a shortage in specialized medical staff. The result is that several health facilities remain without qualified staff to handle cases and especially cases that requires emergency interventions. This is due to the difficult conditions in rural areas as well as the fact that doctors do not prefer to serve at rural areas. While at the same time 80% of the total health facilities are available in the countryside, although the share of manpower to rural facilities does not exceed 20%53. The frequency of beneficiaries visiting the health facility depends largely on the presence of qualified, experienced female doctor or not. It was proved in some places where women were attracted to the health facility due to the existence of a qualified female doctor, trusted by the people, such as the health center in District of Sean – Sana'a.
"If people get familiar with one doctor, they believe in her, and are keen to come to the facility and work in this case is really good. If the doctor decides to leave to work in other place or study, people stop visiting the facility." A Health Worker in Wa’lan rural hospital – Sana'a
In addition, assistant staff is usually unable to offer good performance due to aging. Therefore, in many cases health workers are used as assistant staff54.
The institutional framework for the health sector is witnessing some sort of conflict of interest. While decentralization encourages local government to participate in the management of the health sector, many practical problems associated with the system of decentralization emerged. This mainly includes the conflict of interests between the technical and health needs of citizens from one side and the political interests of the local authority from another side. The interest of political influence and the desire to achieve political ambitions are often incompatible with the goal of improving the health service55. In addition, the conflict of interest arises between governmental health personnel’s personal willingness to work in a more rewarding private sector, and the importance of their presence in public utilities and rural facilities to deliver healthcare services to patients.
52 A meeting with a responsible official in a visited health facility 53 The Third National Health Strategy 2009 – 2015. 54 ˜Wa’lan rural hospital – Sana'a 55 Common review of the Yemeni health sector – March 2008 ˜
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
It was evident from the analysis of institutional issues related to the project that there are some problems of monitoring and evaluation (M&E), according to the interview with the responsible in MoPHP. Monitoring is not conducted according to specific indicators to measure impacts, but rather indicators of health sector performance in terms of service coverage and the number of visitors and the infrastructure of healthcare facilities. Beneficiaries’ satisfaction is not regarded as a monitoring indicator. Regarding the awareness programs implemented by the NCHEI, they are evaluated through quarterly meetings conducted with outreach teams and during which the completed reports, tasks and visits are monitored. One of the main constraints related to monitoring the awareness programs is that monitoring only measures the completion of activities rather than the impact of these activities on the targeted audience.
The lack of consistent and specific indicators that could be measured led to the production of reports that could not be used to objectively measure the progress over time and inform future actions.
Within the HSS framework a preliminary survey was conducted for 46 targeted districts after conducting training needs assessment. A great need for building the staff capacity on topics related to M&E emerged. A central unit for M&E was established and began working with the beginning of 2009 to cope with the integration plan at the level of basic health care services. The monitoring system adopted by the unit includes several indicators to monitor 7 programs related to vaccination and reproductive health. The monitoring system focuses on measuring the situation in health facilities in terms of availability of equipment, medications, vaccines and other administrative and regulatory considerations within the facility. The Program Supervisors collect data. Each facility is visited 4 times per year and monitoring activities are stopped during vaccination campaigns. Some interviewed officials in MoPHP indicated that there are recommendations to start working to integrate the views of beneficiaries, service providers and supervisors in the process of monitoring. This could be regarded as a start for the participatory monitoring and evaluation (PM&E).
Funding Challenges
The challenges are not limited to accessibility problems. Most interviewed individuals indicated that they often resort to private health services due to the absence of many services within the government facility which makes it inadequate to rely on them.
"Everybody started to understand issues about family planning issues, but the lack of the offered service makes women refrain from using it, if a woman is able to go to Shebam or Kawkaban or Sana’a to get the appropriate contraceptive she definitely goes. If she can not afford it , she accepts the situation." Newly wedded women at Arees village – Beni Matar District – San'aa
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
The second-level facilities provide (district and governorate hospitals and rural hospitals) some secondary health services that are not available in the first-level/primary facilities. However, the limited resources of equipment and medications in these facilities do not enable them to receive referred cases. The shortages of medicines lead to reducing the motives of the public to visit the health facility. Some health providers mentioned in this regard, that they sometimes, in cases of availability of medicines, they give priority to the poor to get the medication and deny it from well-off beneficiaries. Well-off are perceived to be more likely able to afford to use the private sector. Despite the sensitivity of this method to the interests of the poor, it lacks transparency and credibility in dealing with the public.
The supply of equipment and medicines is one of the most important interventions to be undertaken by HPP currently under study, which will be supporting the linkage between providing and referral services in cases requiring such services.
Limited resources are also dedicated for training and capacity building. While few CHV at some health facilities indicated that they have received basic training, on communication skills, awareness messages and counseling services, and few CMW received training on breastfeeding and obstetrics, the majority of the staff working in health facilities indicated that they did not benefit from any training56. In facilities where medical doctors are available, they provide on-the-job training to CHV and VMW. There lack of training is seen to be very strongly linked to the limited capacities of the health staff. In addition, the limited resources represent a challenge from paying acceptable incentives for both official MoPHP staff and CHV.
4.2.7.2 Other Bodies Concerned with MNCH in the Targeted Governorates
It is worth mentioning that many donor agencies involved in MNCH are currently working in Yemen. The uniform objective of these donor agencies bodies is the work towards improving mother and child health indicators in order to accelerate for achieving the MDGs. The Technical Committee of MoPHP is considered one of the important coordination mechanisms, which is in charge of exchanging information and experiences among the working agencies. The following part highlights the most important international organizations and donors working in the field of MNCH in Yemen.
56 Midwives at Mohamed El Dora hospital – Gahana – Sana'a.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
4.2.7.2.1 International Organizations and Donors
- Global Alliance for Vaccines (GAVI)
It is one of the most important programs of relevance to HPP since the project plans to adopt a model of outreach and community services, similar to the models applied in the HSS project funded by the GAVI. The program, which will end in 2011, has provided several types of outreach services in the field of women, infants and children health in 64 districts within the framework of the project support to the health sector.
- The Yemeni-German Reproductive Health Program (YG-RHP)
The Program aims to improve access to services and information related to pregnancy, childbirth and diseases through integrating a range of interventions on the central and local level in the MoPHP in collaboration with the private sector, NGOs and the local communities. All these interventions are complementary and aim to support each other. One of the most important projects under this program is the Contraceptive Social Marketing (CSM) Project from the German Development Bank (KFW), which aims to promote family planning services. Administratively, the project affiliates with YG-RHP, in cooperation with Marie Stopes International Organization. The project aims at strengthening the capacity of the private sector, including non-governmental organizations and the commercial sector to increase the use of family planning methods within the political vision of the MoPHP. The project is implemented in seven governorates.
Also within the framework of YG-RHP, the Quality Improvement Program (QIP) is implemented to deal with the problem of deteriorating level of quality in primary health facilities and district facilities, a problem that was prioritized thorough the health sector audit. The program provides support for a selected number of health facilities and enables them to adapt to the European quality management standards. The most significant focus for the project is enhancing the role of volunteer service providers, out of in their effective role in reaching communities. QIP also considers adapting certain standards of monitoring of qualitative indicators associated with the beneficiaries’ satisfaction with the service57. It was observed from the field activities conducted during the preparation of ESIA that in the facilities and areas where QIP is operational beneficiaries showed a high level of satisfaction with the provided service. Target health facilities are keen to consult with beneficiaries through some mechanisms such as consultation services, provided at remote areas and community-based mechanisms such as a health friend of youth in each village, these who have an important and influential role in the delivery of awareness
57 The Yemeni German reproductive health program http://www.yg-rhp.org/qip.htm
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
messages. The project team witnessed an improvement in the level of awareness among women at the areas where the project was implemented58.
-Marie Stopes Foundation
Marie Stopes Foundation is a British organization interested in reproductive health issues, especially issues of family planning. The foundation works in Yemen, with funds from a variety of foreign donors but the most important donors are the Dutch Embassy, the European Union, the German Development Bank, and the Polish-Cyprus project. The organization distributes contraceptives, which are not available in government facilities with low prices that compete with the prices of the private sector (at similar prices to the government facilities). The foundation also provides free consultation for women. The foundation currently works in Sana’a governorate in two districts, in one district in Aden governorate, in one district in Mukalla governorate. Marie Stopes has finally targeted Ibb and Hodeidah governorates. The Foundation started in 2009 the midwives project, which includes training programs for midwives on family planning services.
- United States Agency for International Development (USAID)
The program focus on improving access to mother and child health services, reproductive health services and family planning in remote provinces with low service standards. This is operational in the Governorates of Ma’rib, Shabwa, Omran, Sa’ada and Al-Jouf. The services are delivered through providing support to mobile services and outreach services. The program also built the institutional capacity through a number of important activities, within the scope of activities is supporting community midwives and establishing the Midwives Association.
4.2.7.2.2 NGO’s
A handful of NGOs work at the provincial level on topics related to the project and most important of these associations are Yemeni Family Care Association and the Society of reform who are working on the level of governorates.
58 It was noted during the visit to Moahmed El Dora hospital – Gahana directorate – Sana'a governorate – Gabla health center, Ibb governorate.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Figure 4.31 Service List of the Yemeni Figure 4.32 Yemeni Family Care Family Care Association – Sana'a Association Building – Sana'a
It was evident from the conducted field interviews, that there is not equitable distribution in the services of NGOs, international agencies and donors bodies at target governorates. Table 4.12 shows the relatively modest share of the governorates from donor efforts, especially at Al Baydah governorate, where officials have noted that donor bodies and NGO’s have never intervened. This was among the criteria used for choosing these provinces for the implementation of HPP59.
Table 4.12 The most important activities performed by donor bodies and NGO's working in the field of mother, infant and child health in targeted governorates Governorate ˜ International bodies and NGO’s working in mother, infants and child health Sana’a˜ Marie Stopes Foundation – Yemeni German reproductive health program – NGO's such as Yemeni Family Care Association- UNFPA Reimah˜ Yemeni Family Care Association- recently Dutch NGO Ibb˜ Yemeni German Program (QIP) - EPI Yemeni Family Care Association – UNFPA - Mother and Child Health Program (MNH) Al Dahla'a˜ Mother and Child Health Program (MNH) – UNICEF – Social Fund for Development (SFD) - Yemeni Family Care Association Al Baydah˜ Not available Source: Field Interviews During Preparation of the ESIA
4.2.7.2.3 Private Sector
The private sector plays a prominent role in the supply of health services, especially in light of the multiple challenges that the public sector is facing. The role of the private sector started to emerge since 1990s with the encouragement of the government, which considered that the option of engaging the private sector in supporting public health services a vital option. Although there is no database available with the numbers of private-sector facilities working in the field of mother and children’s health care at the
59 Other criteria included population density, rates of vaccination among children, rates of vaccination of pregnant women against tetanus, rates of births attended by qualified cadres.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
governorate level, the overall numbers indicate that there are about 11,649 private facilities in total in the RoY. The nature of the service provided by these facilities varies between specialized, laboratory and public services. The number of midwife clinics does not exceed 69 clinics in Yemen. Participants in FGDs noted that the families that are financially capable usually resort to private sector services, especially in cases requiring prompt action such as obstructed delivery and severe child illnesses. Poor households usually find many difficulties in accessing private sector services. The main reason for this is the cost of the service,˜60 and the other associated expenses like transportation for the cases living in remote communities. ˜ "All medical specializations are available at hospitals, in addition to all tools, diagnostic equipment; they offer services to patients all day long. On the contrary to public facilities where only few are available." Women at Arees village – Sana'a governorate
60 Interview with a doctor at the Yemeni family care association.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
5. Analysis of the Project Environmental and Social Impacts
Based on the background and the description of the project and guided by the primary and secondary data reviewed by the consultant, the environmental and social expected impacts of the implementation of the project were analyzed. This analysis generally indicated that the project would result in many positive effects, especially on women, infants and children. These groups are considered mostly in need of interventions to improve health conditions.
On the environmental level, there will not be any construction activities during the entire duration of the project. Also, no civil works are to be undertaken within the activities of the project. However, some maintenance work and repairs are needed in some health facilities (Fig 5.1). Some expected impacts are related to the operations activities. These expected impacts are relatively straightforward and limited to the waste generated from different departments, and methods of handling it as well as wastewater from the facility in general, and disposal methods. The other group of the expected impacts could be those resulting from the use of incinerators, generators, boilers and engines and the consequent gas emissions or oil spills on soil. It worth noting, however, that those could not be regarded as impacts of direct relevance to the project. The challenges in the mentioned aspects are general challenges that face the health sector in GoY and the project will not be contributing directly to increase these challenges.
Figure 5.1 Cracks in the Walls at Wa’lan Health Center
On the social level there are multiple positive impacts that are predicted to associate with the project implementation.. It will be noted from the analysis in this chapter that many of the expected social benefits of the project are attributed to the fact that the project is dealing with many root causes of the problem which were previously highlighted in chapter 4. Also, the components of the project are integrated between community-based activities, communication strategy and capacity building activities. In the meantime, the
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
ESIA identified few risks that that should be considered in order to maximize the social benefit. Recommendations to tackle these risks are presented under section 7.2.
5.1 Expected Environmental Impacts
The HPP is largely an outreach based project, which does not include construction activities. However, there will be a preparation phase, which will take place mostly in the pre-implementation period.
As such, the project will consist of two phases: preparation/pre-implementation and operation.
5.1.1 Expected Environmental Impacts during Preparation/Pre-implementation Phase
No environmental impacts are expected to occur in this phase.
5.1.2 Expected Environmental Impacts during Operation Phase
As mentioned above, the project’s main activities consist of outreach services. This means that the project will be building upon already existing services. Therefore, the environmental impacts, though they do exist, can be considered to be relatively limited in light of the increase in the volume of services. This means that the impacts listed below already exist to a certain extent.
However, the Operation Phase is the most important phase of the project. It is considered to be the longest-lived in terms of the timeframe where most of the projects activities, if not all, are planned to be carried out. It includes a number of expected environmental impacts during the implementation of the project. These impacts in most of the cases concern, in the first place, the healthcare sector in Yemen in general. The contribution of the project’s activities to these impacts is relatively small and has minor effects.
However, the expected impacts would generally consist of the following:
5.1.2.1 Impacts Related to Improper Handling and Storage of Chemicals and Drugs
The general role of the healthcare sector is based on services supply and provision. This is naturally based on the use of chemicals and drugs in most project activities. The increase in the quantities and types of chemicals and drugs used is inevitable. This includes chemicals directly used in medical processes involving patients as well as chemicals used in laboratories for medical analysis.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
1. Impact
Improper handling of chemicals and drugs can cause a number of health effect. These include:
- The deterioration and/or corruption of chemicals and drugs due to improper conditions of usage and storage. This affects the patients’ health and weakens the quality of healthcare services provided.
- Easy uncontrolled access of the population, especially those untrained and unaware, to these chemicals and drugs.
- Soil contamination due to direct contact with spilled and dropped products.
- Surface and ground water contamination in case of direct contact.
- Increase of expenses on drugs and chemicals which can present a burden on the project’s budget.
2. Significance of the Impact
Though the impact has multiple effects on the environment and on human health, it is not a direct impact of the project and its significance is minor. This is due to the fact that the situation already existing will slightly change by the expansion in service provided by the project’s healthcare facilities.
3. Required Mitigation Measures
It is recommended that the healthcare sector avoid the significance of that impact through some mitigation measures that should include the design and implementation of a simple and low-cost management system for handling and storage of chemicals and drugs. For that the following actions need to be considered: - A strict and proper system of handling and storage of chemicals should be put in place.
- Training programs to personnel dealing with the handling and/or the storage of these products.
- Regular awareness programs for all healthcare facility staff on the hazard caused by the unsafe contact with chemicals and drugs.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
5.1. 2.2 Inappropriate Disposal of HCW Generated during Outreach Activities
1. Impact
The improper disposal of HCW generated during outreach medical services, especially used syringes, needles, and other hazardous wastes affecting the health of the local community inhabitants, especially children.
2. Significance of the Impact
During the outreach services the healthcare service will be delivered in remote areas where no other source of HCW exists. This means that the outreach service is the only generator of this type of waste. The inappropriate disposal of these HCW in these areas might have a negative effect on the receiving community and environment. However, the expected amount of HCW generated during the outreach services is low and the significance can only be estimated as low to medium .
3. Required Mitigation Measures
• Midwives" or health practitioner providing outreach services should be equipped with the necessary HCW consumables (red bags and sharp boxes) when providing relevant outreach activities.
• "Midwives" or health practitioner should then bring back the filled red bags and sharp boxes to the health care facility for handling and burning with the rest of the facilities’ HCW. An alternative would be for the "Midwives" or health practitioner to burn the HCW on site and burry the ashes.
• "Midwives" and other health practitioners providing outreach services should participate in the training/educational program introducing and explaining the appropriate HCW management practices
5.1.2.3 Mismanagement of Increased Quantities of Municipal Solid Waste Generated by Healthcare Facilities
1. Impact
The activities of the project could result in minor increase in the numbers of patients, visitors and staff of the targeted fixed primary health facilities. This would result in a relatively minor increase in the quantities of domestic solid waste generated. Mismanagement of domestic solid waste, in particular, inappropriate disposal in the vicinity of the facilities represent a negative impact of the project. This impact is
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
particularly valid due to the fact that domestic waste most likely contains HCW and access to this waste is easy for neighboring population especially children. In this case, the main party concerned by this impact is the healthcare sector in general.
2. Significance of the Impact
The significance of this impact in relation to the healthcare sector could be considered as important. Yet, as regards to the direct link between this impact and the project activities, this impact is of a minor significance.
This is due to the fact that municipal waste is already experiencing mismanagement in almost all the study area. In addition, municipal waste has no health risks unless mixed with hazardous wastes. Otherwise the significance would be calculated differently.
3. Required Mitigation Measures
• Infectious/hazardous healthcare waste stream should be segregated from the domestic waste stream. • In the case no municipal solid waste management services are provided to a participating facility, the domestic waste generated from the facility should be dumped in the closest dumpsite.
5.1.2.4 Use of Poorly Maintained Electric Generators
1. Impact
As a result of the increased number of visitors, the expansion of the base of service provision, the poor power supply service offered by the municipality to healthcare facilities in some areas and the absence of electricity in most rural areas, most of the health facilities possess electric power generators. These generators are mainly operating on fossil fuels, especially diesel. They also consume a large amount of oil and lubricants, as well as used spare parts. The major environmental impact is:
- Air emissions caused by the generators as a result of incomplete fuel combustion inside the engine. This is due to the lack of maintenance and overuse during operation. - Risks resulting from potential spills of fuel or oil and grease causing the pollution of soil and surface and groundwater. - Noise generated from operating for long periods. - Spare parts resulting from maintenance operations and difficulties in safely disposing it
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2. Significance of the Impact
The impact’s significance here could be considered as low. This is due to the relatively limited capacity of power generators. On the other hand, the number of healthcare facilities that have generators and boilers is not very high.
The associated impacts are those related to air emissions or oil spills could be within the low limits.
3. Required Mitigation Measures
Mitigation measures include the following: - Ongoing and reliable maintenance for the generators to ensure complete combustion of fuel in order to reduce the amount of gas emissions upon operation. - Securing and carefully handling fuel, oil and grease tanks to avoid spills. - The generator should be placed in a separate room, where basic insulation system for noise is applied. - Upon the occurrence of any spills, a sufficient quantity of sand should be flushed on the spilled material, and it must be completely removed in bags and disposed properly. - Proper disposal of used spare parts.
Table 5.1 indicates the environmental impacts expected to generate during the operation phase of the project and suggested mitigation measures to reduce these impacts.
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Table 5.− Environmental Impacts during Project Operation and Suggested Mitigation Measures
Impact Likelihood and Severity Significance Mitigation Measures Effects
eliminate impact Improper handling and storage of chemicals and drugs High likelihood low significance
High likelihood of low Eliminate impact Improper Management of Hazardous healthcare Waste Generated by the infection and serious significance Project Health Facilities heath risk
High likelihood of low Eliminate impact Inappropriate Disposal of HCW Generated during Outreach Activities infection and serious heath risk Low Eliminate impact Mismanagement of Increased Quantities of Municipal Solid Waste High likelihood significance Generated by Healthcare Facilities
Low Eliminate impact Use of Poorly Maintained Electric Generators High likelihood significance
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
5.2 Expected Social Impacts
5.2.1 Expected Social Impacts during Preparation/Pre-implementation Phase
5.2.1.1 Creating Temporary Economic Opportunities
No considerable social consequences are expected to result from this phase. It is thus perceived that the only social impact of this stage is to create some local job opportunities through the support to the referral services in the fixed existing health facilities. This will likely include the supplying of the necessary equipment which would qualify the facility to perform referral services. Within this framework, the project is expected to create opportunities related to transporting equipment for facilities (drivers, local contractors, etc.) or to contractors, traders and importers.
Significance of the Impact The creation of temporary economic opportunities during the preparation/pre- implementation phase has a temporary positive impact.˜
Table 5.2 Impact Significance during Preparation/Pre-implementation Phase Impact Likelihood significance Mitigation measures and severity Creating some local High likelihood ˜ Positive No need for job/economic mitigation measures opportunities
5.2. Expected Social Impacts during Operation Phase
5.2.2.1 Job Opportunities for Women in the Field of Community Health
The project will contribute to providing several outreach services related to mother, neonatal and child health. It is expected, in this context that the project will be based on real effective models from the community and will benefit from past experiences in this area. Perhaps the component of Community Health Volunteers (CHV) is one of the elements through which the spirit of volunteerism can be stimulated and maximized. The project is planned to benefit from the available local human resources to ensure the improvement of mother and child services by attacking the problem of difficult access to health facilities and the absence of some types of services.
It is expected that the female CHV will contribute to raising awareness of mothers in topics related to the care of sick children, child growth and child nutrition, which are
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special components of this project61. In addition, female CHVs will refer patients to health facilities, as needed, will provide ongoing awareness to families and will mobilize members of the community during vaccination campaigns and other community activities. The volunteers will also produce monthly reports, which are one of the important mechanisms for monitoring the project.
Figure 5.2: The Organizational Structure for CHV
Primary Health Care Central Level Steering Sector (Working Committee Group and Relevant stakeholders)
Governorate
Local Council The Health Office and Relevant Governorate Level The Head of the Agencies Primary Health Department
Directorate Local Directorate Level Council and Relevant The Manger of the Health Agencies and Population Office
Village Level Health Staff Doctors and Assistant
Natural Leaders Community Health
on Village Level Volunteers (CHV)
Source: A presentation from the general department of family health in the community volunteers program
61 The interview with a midwife trainer and a teacher in the higher institute for health affairs showed that some health centers raise awareness among mothers about infant nutrition and provide samples of a balanced meal for a 5 month baby, but the lack of the resources led to the termination of this program.
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The project will contribute to the creation of employment opportunities for girls and women, will enhance their communication skills and will support their awareness and their role within their communities.
"We have about 1200 male and female CHV; some of them are working at the targeted governorate of Ibb. The local council contributes to choosing those volunteers, and they are an effective mechanism. Young men and women are widely interested in this job although they only receive transportation allowance." Head of the NCHEI – Sana'a
Significance of the Impact
This is a positive impact that is predicted to contribute to several positive social benefits at target governorates.
5.2.2.2 Improving Women’s Access to Pregnant Women’s Health Services
Perhaps the greatest current challenge is the difficulty that women have accessing health services and a lack of awareness, in particular of matters related to childcare and family planning. This is in addition to the lack of efficiency of the provided health services, in a manner that does not qualify the referral services to the needed quality. The project will contribute to supporting outreach services and supporting facilities to receive transferred cases to overcome these obstacles and to benefit the beneficiaries. This, in turn, will mean better usage of family planning services by women, child health, awareness and health awareness, especially in remote areas in target governorates. Achieving this impact in turn will enhance the opportunity of target governorates to achieve the required fifth goal of the MDGs, and in improving the health of the pregnant women. The availability of medicines, contraceptives and other supporting equipment at target health facilities will mean improved women’s access to health service facilities.
Significance of the Impact This positive impact should contribute to many positive social benefits in target governorates.
5.2.2.3 Improving Child Health and Safety at Remote and Disadvantaged Areas
This impact will directly be achieved through support groups and outreach activities which will have a role in achieving wider coverage for vaccination activities. This will eventually reduce child infections and diseases, especially at remote rural areas which are not covered by the primary services. In addition to that the implementation of the components related to child nutrition will contribute to achieving this positive effect. The project will implement specific components related to promoting child nutrition
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(community-based nutrition program) and based on successful models implemented under the HSS and the program is in full coordination with the ministry and the methodology documented in the guidelines, and based on practical learning. However, the existing project is facing some financial problems that impede the implementation. This should be taken into account by HPP through providing the necessary resources and taking the lessons learned into consideration.
Moreover, an indirect positive impact on children will be attained through raising awareness of mothers about follow-up of child growth and also the importance of family planning which will contribute to improving the overall fostering environment for children and enhance their opportunities in receiving more care from their families.
Significance of the Impact This positive impact should contribute to many positive social benefits in targeted governorates.
5.2.2.4 Enhanced Level of Trust between Beneficiaries and Government Agencies
Beneficiaries expressed that the inadequacy of existing health facilities and lack of appropriate equipment are of the important reasons that compel them to resort to private services. ˘Yes it is important for the pregnant women to receive all services but the center is not equipped. To give birth at an equipped facility this is a dream for Yemeni people.˘ Mother in laws meeting – Azlet El Arees Beni Matar District– Sana'a governorate
It was planned within the third component of the project, to design and implement a M&E system for HPP. This system is planned to include many participatory activities, which aims at incorporating the views of the beneficiaries. These activities will play a role in moving with the M&E process from being a conventional process where the evaluator performs the major role to a more participatory process that recognize the role of community as an active partner in planning and evaluation. Through consultation with the beneficiaries in implementing several mechanisms such as pre and post studies and other activities, a step forward will be taken on the path of empowering women, boosting participation and enhancing the sense of ownership to the project. This is perceived as a positive impact that will crease communities’ keenness to receive the service and enhance the relation between the service provider and the beneficiary.
Significance of the Impact This positive impact should contribute to many positive social benefits at target governorates
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5.2.2.5 Building the Capacities of Human Resources
The lack of capacities of the existing human resources is one of the most pressing problems suffered by users of the public health system. It is planned that the project will fund activities designed to empower human resources including health volunteers in the health sector to enable them to provided quality services in the areas of MNCH. The project will contribute on the central level of the MoPHP, to supply the necessary technical support needed to enhance the quality of the guidelines and programs related to human resources in the concerned sectors and also in the design of training programs necessary to support the delivery of services. The project will also contribute to the implementation of some capacity building activities.
Within this framework, an assessment of needs of technical support will be conducted in the targeted governorates. This will be done to ensure that the designed training programs are driven from the actual needs for the targeted groups. It should be noted that human resources training programs should include training programs in participatory activities and methods of PM&E in order to serve the second component of the project. This type of training is considered as a new field for the health staff that is more familiar with the conventions monitoring methods that do not pay a lot of attention to engaging beneficiaries to measure their level of satisfaction.
In addition to that, the project will adopt the supportive supervision system, where the role of supervision exceeds being a one side observation to the target staff, to a more interactive approach based on mutual contact. This approach will contribute to the empowering and engaging human resources and giving them the opportunity to express the practical challenges that they face and encourage them to overcome these challenges collectively and learn from them.
Significance of the Impact This positive impact should contribute in many positive social benefits in the targeted governorates.
5.2.2.6 Raising Community Awareness
As noted in Chapter Four of this ESIA, the low level of awareness is one of the important reasons that causes the continuing decline of the indicators associated with maternal and child health. The project is expected to have a positive impact in this regard through strengthening communication channels between community members and the various groups of service providers who will have a role in changing the misconceptions and raise awareness of the community. The communication strategy planned under the project
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will pay attention to the need for establishing communication and dialogue channels between service providers and the targeted communities. The human resources that will be used in the outreach services will play major role in enhancing credibility and stimulating awareness among the targeted population. It should be noted that raising awareness should not be limited to women only, but should target other influential groups that play a role in the decision making process. This, most importantly, should include mothers-in-law and husbands as will be explained in detail.
Significance of the Impact This positive impact should contribute to many positive social benefits in the targeted governorates.
5.2.2.7 Increasing Women’s Sense of Security
Participating women indicated that the distance to the health facilities or lack of quality obstetrics services or CMW, and their inability to go out at night to receive obstetric services are the causes for increasing the pregnant woman sense of insecurity and fear, and disorder especially with the delivery date approaching. It should be noted that, despite the importance of the role played by awareness programs in making women familiar with warning signs and other signs of risk but knowledge alone, awareness is considered to be of limited value unless emergency alternatives are developed. Moreover, sometimes knowledge of the potential risky consequences can even generate a growing feeling of fear and insecurity.
It is expected that the project will support women’s sense of security through improving the referral services and equip health facilities to receive such cases. However, the project must deal with the issue of working hours of responsible staff at the targeted health facilities to ensure their availability when they are needed.
Significance of the Impact This positive impact should contribute to many positive social benefits in the targeted governorates.
5.2.2.8 Improving the Process of Monitoring Changes and Observing Indicators
It is expected that the extensive outreach activity will contribute to increasing access to target groups in a more focused way, in addition to that the methodology for PM&E (which will be proposed later in this study in Chapter 6 under the ESMP) will help to employ the outreach activities more effectively through collecting accurate data from the target areas. The adopted monitoring methodology of the project will be impacts-based
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and results- oriented. Thus new indicators will be included to measure the level of service quality and the impact on beneficiaries. There will be a need for capacity building and training on this type of impact monitoring.
Significance of the Impact This positive impact should contribute to many positive social benefits in the targeted governorates.
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Table 5.3 Impact Significance during Operation Phase
Impact Likelihood and Significance Mitigation measures severity New job opportunities High likelihood Positive ˜ No need for mitigation especially for women at measures ˜ the field of public health Improving the access of High likelihood Positive ˜ No need for mitigation women to pregnancy measures ˜ health services Improving child health High likelihood Positive ˜ No need for mitigation and safety at remote and measures ˜ disadvantaged areas˜ Supporting credibility High likelihood Positive ˜ No need for mitigation between beneficiaries and measures ˜ governmental bodies˜ Capacity building for High likelihood Positive ˜ No need for mitigation human resources measures ˜ Raising community High likelihood Positive ˜ No need for mitigation awareness especially measures ˜ among women˜ Increasing the feeling of High likelihood Positive ˜ No need for mitigation safety among women measures ˜ against health emergency cases Improving the process of High likelihood Positive ˜ No need for mitigation measuring change and measures ˜ observing indicators
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6. Project Alternatives
6.1 “No Project” Alternative
HPP is one of the important projects expected to result in many social and environmental benefits. The project would help Yemen to achieve some strategic goals such as the Millennium Development Goals, which is one of the major challenges. On the community level, the project will contribute to the achievement of many benefits to members of the community, especially women and children who are considered the most marginalized groups in Yemeni society. The project will create jobs, raise awareness and support relations between service provider responsible and community members. It was noted from the previous chapter, that the most expected negative impacts of the project are limited or moderate impacts and will be dealt with through mitigation measures and these measures will contribute significantly not only in reducing the negative effects but also to the maximization of benefits to beneficiaries among the members from target community.
Based on the ESIA team considers that there are no environmental or social reasons leading to the rejection of the project and resorting to the alternative "without the project".
6. 2 Alternatives during Operation Phase
6.2.1 Alternatives to Project Management
Regarding the intensity of the activities required under the environmental and social management plan (ESMP), the need arise to having a separate Project Administration Unit (PAU) with separate structure in order to be fully in charge of implementing the project activities (Chapter Seven of this report presents the proposed administrative structure to manage the project). The current alternatives include:
Alternative 1: Project Management by the General Department of Family Health
The General Department of Family Health and the General Department of the Reproductive Health are the most relevant departments to the project with relevant experience of the various activities associated with the project. The General Department of Family Health will be in charge of preparing the project and its implementation. And despite the fact that they are the most competent departments of the MoPHP to manage the project, the work load and duties on both the departments and the fact that they are participating in the implementation of many national programs such as vaccination programs, will unlikely allow the to carry out more duties for managing HPP.
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Alternative 2: Create a Project Administration Unit (PAU) under the Supervision of the General Department of Family Health
This alternative includes the establishment of an independent management unit for the project which should administrative and supervisory affiliate to the General Department of Family Health and benefit from the practical experiences of both the concerned departments.
Alternative 2 is perceived to be a more efficient alternative to ensure the full time commitment to the HPP along with gaining the practical experience form the departments of relevance.
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7. Environmental and Social Management Plan (ESMP)
This section contains the environmental management plan aiming at the control of environmental impacts analyzed in section (5) of this report. Mitigation measures have been identified to reduce the effects of expected negative impacts. It presents proper procedures for monitoring various environmental impacts, and to document the actions that should be taken.
The following section explains the management and social monitoring plan that include capital actions and monitoring actions or awareness and capacity-building actions aiming mainly at reducing the negative impacts during the operation phase and working to maximize the positive impacts.
The social management plan has been developed in the form of recommendations and guidelines to handle any potential social risks and maximize the project’s social benefits. It should be noted that the various components of the project, as referred to in the project ToRs and the Project Appraisal Document (PAD), are characterized by being holistic and this approach suggests that some of the project activities will actually work to mitigate any potential social risks. Most recommendations proposed by the ESIA team are, in fact, capacity-building activities and activities to enhance the M&E process with more emphasis on participation and raising community awareness.
7.1 Environmental Management Plan during Operation Phase
The objective of the environmental and social management and monitoring framework is to establish a mechanism for the implementation of mitigation measures. It also aims at monitoring the effectiveness of relevant environmental indicators. The framework for environmental and social management and monitoring sets the roles and specific responsibilities to be undertaken by the parties involved in the implementation, supervision and monitoring. This section also includes an assessment of the efficiency of the implementing agencies, and to identify their competencies and resources to implement the framework.
7.1.1 Handling Solid Waste
The solid waste consists mainly of the following; regular domestic waste, non hazardous health-care waste and hazardous or infectious healthcare waste.
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A. Mitigation measures:
- All health facilities within the project will be contracting with a certified cleaning company to ensure regular cleanliness; with a condition that waste disposal will be conducted in a licensed sanitary landfill, to ensure sorting and discrimination of waste by trash collectors. - Wastes of economic value should be separated (such as office paper, metals, scrap, etc.) in the case of waste separation at the source; it should only be sold to licensed companies for the recycling of paper or packages and other substances, in a safe and secure manner. - The administration of health facility should monitor and supervise the movement of waste transport vehicles within the facility to ensure that no miss-disposal of any waste, and / or unintended dropping of debris from transporting trucks
B. Documentation and Monitoring Procedures:
- Documenting the amounts of segregated waste and packaging material, and the sold quantities and keeping photocopies of licenses and identities of contractors and distributors who buy the waste in the environmental register of each facility. - To keep within the environmental register of each facility, the agreement as well as records of the delivery of waste paper bags "containers", containers and non- recyclable packaging that are to be incinerated properly and safely disposed
C. Responsibility:
- Management of the concerned health facility - MoPHP - Designated administrative authority concerned with environmental issues in Yemen (Ministry of environment)
Annex – Represents a set of primary guidelines aiming at helping healthcare facility management on the safe procedures to be followed for the proper management of waste including the healthcare wastes.
7.1.2 Controlling Emissions
A. Mitigation Measures:
- Conduct periodic maintenance of medical incinerators, boilers and power generators to ensure the efficient combustion of fuel.
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B. Documentation and Monitoring Procedures:
- Monitoring the concentrations of pollutants in the work environment where carbon oxides, nitrogen oxides and organic materials are monitored on quarterly basis, if possible.
C. Responsibility:
- Project Management - Management of the concerned health facility - MoPHP - Designated administrative authority concerned with environmental issues in Yemen (Ministry of environment)
7.1.3 Controlling Chemical Substances and Pharmaceuticals
Many chemical substances and pharmaceuticals are considered as harmful and hazardous substances to human health and the environment. This is because chemicals are characterized by one or more of the following characteristics
- Poisoning - Disruption of genetic elements - Carcinogenicity (causing malignant tumors) - Corrosion - Inflammation or ignition - Reactivity - Explosion - The sensitivity to collision
Chemical and pharmaceutical substances as well as oils, grease and petroleum products are the most hazardous substances that can be found in health facilities. Controlling these materials is made through the control of possible leaks from hazardous materials containers or means of transportation, as well as during handling and usage. Annex 2 is a set of primary guidelines on the handling and safe management of drugs and equipments in healthcare waste facilities.
A. Mitigation Measures:
- The management of each health facility, should register any hazardous materials exist within the facility in addition to the quantity and the degree of hazard.
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- The health facility administration should highlight locations of hazardous materials on the facility’s layout to ensure access to those places for protection and prevention in emergency situations (such as a fire). - Surrounding power generators, fuel tanks (diesel, for example) and the oils within the health facility with embankments, lined with impervious substances to prevent any leakage from these tanks. It also helps collecting spilled hazardous liquids in reservoirs in the surrounding area. - Surrounding embankments of the reservoirs with sewers to drain rain water, washing water, and firefighting water. - In the event of any leakage to the soil, leaks should be absorbed in sandy soil, then collected, and placed in hard plastic sealed bags until incinerated completely at a licensed site for hazardous waste. - Conducting the necessary awareness programs for all persons handling these substances according to their sensitivity and the safe handling methods. - Ensuring all persons handling chemical substances are following necessary instructions for safety and health. - Clothing and personal protection equipment, such as gloves and masks, especially when there are possibilities of leakage or exposure to infection or injuries.
B. Documentation and Monitoring Procedures:
Documenting any accident of leakage at the environmental record for each health facility indicating the time of leakage, date, reasons, quantity of affected soil (if any) and methods of disposal.
C. Responsibility:
- Project Management - Management of the concerned health facility - MoPHP - Designated administrative authority concerned with environmental issues in Yemen (Ministry of environment)
7.1.4 Handling Hazardous Waste
This section includes a focus on procedures to be followed in handling hazardous healthcare waste. It is mainly the waste that could cause infection, injury, diseases, or because of toxic contamination or other hazards that may be caused by this type of waste. The impacts of such waste happen in case of a cut or wound in the skin, or through inhalation or swallowing, or friction with wounds or mucous membranes in the body.
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Any person handling this waste at the health facility can be subject to these risks, such as workers or service users, visitors or workers in the field of removal and disposal of healthcare waste.
Figure .1 Proposed Systems for the Safe Handling of Hazardous Waste at Health Facilities
Segregation of Wastes at source
Collection and transfer of wastes within the health facility
Temporary storage of wastes
Treatment of wastes inside or outside the facility
Transporting waste outside the facility
Final disposal (landfill – dumpster)
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A. Mitigation Measures:
This part includes the description of the procedures to be available and implemented on several levels.
First: Vaccination and immunization programs for workers and handlers of medical waste:
In addition to regular immunization programs in health facilities, according to the guidelines in the organization, the following preventive measures must be taken into account:
- Protecting workers engaged in the movement, transport and storage of health-care waste, particularly possible infection waste, it is necessary to be immunized against viral hepatitis type II (B), vaccination is taken in three doses, 8 to 10 weeks between each dose. No tests are required before vaccination. Vaccination can be taken at any time and does not conflict with any other vaccination taken in the same time. - Protecting workers at risk of tuberculosis, they should be immunized against the disease by the infection using BCG, a test must be conducted for Tuberculin before immunization, and no immunization if the test proved positive. In general, employees who are vulnerable to tuberculosis related to the job nature, must be examined using Tuberculin, each 6 - 12 months, and if there was a shift at any time from negative to positive, it must be treated using isoniazide.
Second: The procedures that should be taken in case of exposure to infected needles: Immediately after the accident, any particles or residues in wounds or in the surrounding exposed skin should be washed immediately with warm water and soap, and then to work on: - Disinfect the place of the wound twice using alcohol, or any other disinfectants are described. - In case of any sprinkles in the eyes, it’s better to cover the whole area with a neutral antiseptic solution. - Change contaminated clothing with sprinkled remains or materials of concern. - Call the ambulance if necessary. - Identify the source and type of the potential infection risk substance, which should be monitored whenever possible. - Asking for medical assistance, immediately after the previous procedures, in order to reduce the rate of serious acute effects of exposure to risk of infection
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- Work on writing the report of the incident and send copies to the head of department (or management) where the wounded is employed and also to the nearest nurse responsible for infection control or to the concerned committee. - Safety and occupational health. - Proceeding to take the necessary measures to diagnose the type or types of infections related to the risk. - Work to test the source (or sources) of possible infection by serological tests, (HBsAg, anti-HCV, and HIV antibody), taking into account the effective use of rapid tests. - Work to re-evaluate the current status of infectious waste materials management, waste sharp elements, or individual behavior, or use of personal equipment and means of protection, etc., so as to avoid the recurrence of such incidents.
Third: Procedure that should be taken to ensure there are no puncture injuries or injuries from sharp metal medical equipment:
- Avoid the risk of exposure to the causes of infection through training, and the use of means of personal protection - such as gloves and masks covering nose and mouth – while serving the patient, gloves should be changes before serving the next patient. - Avoid exposure to sharp substances and needles that may cause severe injuries, by avoiding the re-covering needles or bending or breaking them, as well as to avoid the dumping of waste outside the allocated containers (thick bags for most of the waste and safety boxes resisting hole for needles.) - Avoid direct contact with any of the types of hazardous health-care waste. - To ensure personal hygiene such as washing hands, and clothes. Note the possibility that microbes might be gathered in accessories such as watches, jewelry, etc.
Fourth: Procedures for handling medical waste:
- Agreeing with suppliers of hazardous materials containers such as packages of medical solutions and consumables, where the possibility of risk is the leftover hazardous material in the package, to return the empty containers after use. - Keeping a special register of substances that may generate hazardous waste (to be included in the contents of the environmental record for each facility) that contains the date of supply of containers, the date of return of empty containers to the supplier, quantity, production date, and the means of temporary storage. - Make sure to tightly close bags containing waste.
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- Ensure secure storage areas that are not subject to tamper from children or animals or garbage workers. - Use one of the means of open burning (figure 7. 2), such as built incinerators, or drums, or metal boxes, or at worst digging at an appropriate depth and then burying after incineration. - Take into account burning holes are not too deep, which may cause erosion of burning remains to rain or flood water, in addition to that the burning process should not be at the highest wind-up area to avoid impacts to residential areas by the surrounding gas emissions resulting from burning. - Get rid of the sludge of medical sewerage in special cells for the burial of hazardous waste in a landfill that includes such cells, or dispose of them by safe burning.
˜˜˜ Figure 7.2 Open Burning in a Barrel or Constructed Incinerator
B. Documentation and Monitoring Procedures:
- Preparing bags of different colors of hazardous medical waste and training staff to use them regularly. - Monitoring the quantities and types of containers of lubricating oils and grease used in generators and motors (cars in outreach service) according to the model proposed in the environmental register annex No. 2. - Registering all employees and personnel handling hazardous medical waste and the registration dates and schedules of immunizations. - Including data and documents of transport and disposal of sludge in the environmental register for each health facility.
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Figure 7.3 Colored Bags for Distinguishing between Wastes
C. Responsibility:
- Responsible of the concerned health facility - MoPHP - Ministry of environment
7.1.5 Controlling Noise
The most important potential sources of noise are what may result from power generators, if any.
A. Mitigation Measures:
- Follow the professional methods of prevention such as the use of ear plugs for personnel handling generators directly, covering the ears, regular medical examination and respect for the time limits for exposure to noise. - Putting generators in separate rooms that should be designed to isolate or reduce noise significantly.
B. Documentation and Monitoring Procedures:
- Monitoring noise within the work environment at various locations of the health facility including the places of providing the service, once every three months or regularly based on the rate of operating the generator. This is in addition to monitoring noise in the sides of the site and registering records in the environmental register for the health facility.
C. Responsibility:
- Project Management - Management of the concerned health facility - MoPHP
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- Designated administrative authority concerned with environmental issues in Yemen (Ministry of Environment)
7.1.6 Training, Awareness and Capacity Building Programs on the Safe Handling of Healthcare Waste
Training and the provision of information should be an important element for ensuring quality in order to implement the responsibilities of health care waste management department. Training should include all health facility personnel, especially those who have specific responsibilities in the system. Subsequently, all the physicians, the nursing staff, technicians and health facility workers should be given their share of training and awareness-raising concerning methods of managing health care waste.
It is recommended to design and implement a training program based upon the experience of a highly qualified concerned body with health facilities, based on the recommendations included in the guide published by the World Health Organization, according to the quality of training recipients. The training focuses on the quality of training recipients to determine their training needs; the following are some preliminary suggestions in this regard:
- Identification of target groups in the training program; staff in the health service such as: workers in waste management department, responsible on the departmental level, nursing staff, technicians, workers, midwives and health workers, the committee on infection control and doctors of the facility. - Determine the topics and the training needs of each group which includes:
First: Healthcare waste management programs in general and hazardous waste in particular include:
- Definition of the types of health-care waste - Health and environmental impacts of waste. - Regulate waste management. - Methods of health care waste management (Code of Practice.) - Instructions for separation (sorting) of waste. - Instructions and requirements of temporary waste storage. - Instructions and the requirements of waste treatment. - Instructions and the requirements of external transport of waste. - Review the activities of waste management system. - Legislative aspects of managing health-care waste
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Second: Anti-infection programs including: - Sources of infection - The basics and principles of infection control - The basics and personal hygiene practices
Third: Training methods and training tools including: - Training classes - On-job training - Training classes and on job training - Tools and training aids using information and data
A. Responsibility:
- Project Management - Management of the concerned health facility - MoPHP
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Table 7.1 Environmental Management Plan Matrix during Project Operation
Impact˜ Mitigation measures˜ Project Organizational Direct Supervision (Cost ˜USD)˜ Phase˜ Responsibilities˜ Supervisor ˜ Mechanisms A proper system of handling From planning Consultant and General • Follow up on 10,000.00 Improper handling and storage and storage of chemicals and at all MoPHP, project department of storage of chemicals and drugs should be put in place. phases management Chemicals and conditions ˜ Drugs in the • Review of MoPHP storage registries
Training programs for From planning Training General • Review training 20,000.00 personnel dealing with the and at all consultant, department of needs handling and/or the storage phases Project Chemicals and questionnaires, of these products in management, Drugs in the and results of participating facilities. MoPHP˜ MoPHP organizational assessment • Review consultant report • Assessment of post training performance Segregating HCW from Operation Healthcare facility MoPHP • Regular facility Operational ˜ Improper Management of point of generation inside phase management visits Hazardous Healthcare Waste the facility and providing the Generated by the Project Health necessary HCW Facilities consumables, such as red bags and sharp boxes. Incineration of HCW on site Operation Healthcare facility MoPHP • Regular facility Operational ˜ whenever possible. phase management visits Incineration should be • Incineration carried out within a confined registry regular structure/kiln located in a control place so as to have the least possible air pollution impact on the facility itself or on the neighboring community.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Impact˜ Mitigation measures˜ Project Organizational Direct Supervision (Cost ˜USD)˜ Phase˜ Responsibilities˜ Supervisor ˜ Mechanisms Ashes resulting from the Operation Healthcare facility MoPHP • Field visits˜ Included in project burning of HCW should be phases management budget managed/disposed of together with the domestic solid waste of the facility Providing guidelines for Project General MoPHP • Review facilities’ Included in project sound management of HCW planning and department of needs list budget to the participating facilities. implementation family health, • Field supervision Project for facility˜ management Assigning a HCW officer Project Healthcare MoPHP • Assessment of Operational ˜ for each participating facility planning and Facility overall from among the existing implementation Management performance staff to be responsible for • Regular implementation. evaluation of compliance with required measurements
Training/educational Project Training MoPHP • Review training 30,000.00 ˜ program to introduce and planning and consultant, needs explain the HCW implementation Project questionnaires, management guidelines to management, and results of relevant staff of participating MOHP organizational facilities. assessment • Review consultant report • Assessment of post training performance Periodic audits conducted by Operation Consultant, MoPHP • Field visits 2000.00 per governorate Ministry of Health relevant Phase MoPHP • Review staff to ensure facility consultant compliance with HCW reports guidelines.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Impact˜ Mitigation measures˜ Project Organizational Direct Supervision (Cost ˜USD)˜ Phase˜ Responsibilities˜ Supervisor ˜ Mechanisms "Midwives" or health Planning and Socio–economic General • Regular control Bags: Inappropriate Disposal of HCW practitioner providing all project consultant, department of and surveillance 0.2 USD / midwife/ Generated during Outreach outreach services should be phases Project family health • Field supervision working day Activities equipped with the necessary management • Site visits HCW consumables (red • Interview Sharp boxes: bags and sharp boxes) when community ˜0.27 USD / midwife / providing relevant outreach working day activities. Midwives or health Planning and Project General • Regular control Operational ˜ practitioner should then all project management department of and surveillance bring back the filled red phases family health • Field supervision bags and sharp boxes to the • Site visits health care facility for Interview handling and burning with community˜ the rest of the facility’s HCW. An alternative would be for the "Midwives" or health practitioner to burn the HCW on site and bury the ashes. "Midwives" and other health Planning and Training and MoPHP • Review training 20,000.00 practitioners providing all project organizational needs outreach services should phases consultant, questionnaires, participate in the ˜Project and results of training/educational program management, organizational introducing and explaining Healthcare facility assessment the appropriate HCW management • Review management practices. consultant report • Assess post training performance
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Impact˜ Mitigation measures˜ Project Organizational Direct Supervision (Cost ˜USD)˜ Phase˜ Responsibilities˜ Supervisor ˜ Mechanisms Infectious/hazardous From planning Project MoPHP • Continuous Operational Mismanagement of Increased healthcare waste stream and at all management monitoring of Quantities of Municipal Solid should be segregated from phases Healthcare facility compliance Waste Generated by Healthcare the domestic waste stream. management • Regular visits Facilities
In case no municipal solid From planning Project MoPHP • Monitoring of Operational waste management services and at all management, continuous are provided to a phases Healthcare facility compliance participating facility, the management • Regular visits domestic waste generated from the facility should be dumped in the closest dumpsite.
Ongoing and reliable All project Project Maintenance • Checkup on Operational Operation of Poorly Maintained maintenance for the phases management, General operation Electric Generators generators to ensure Healthcare facility Department in conditions complete combustion of fuel management MoPHP • Regular in order to reduce the maintenance amount of gas emissions visits upon operation.
Securing and carefully All project Project Maintenance • Checkup on Operational handling fuel, oil and grease phases management, General operation tanks to avoid spills. Healthcare facility Department in conditions management MoPHP • Regular maintenance visits
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Impact˜ Mitigation measures˜ Project Organizational Direct Supervision (Cost ˜USD)˜ Phase˜ Responsibilities˜ Supervisor ˜ Mechanisms Generators should be placed All project Project Maintenance • Checkup on Operational in a separate room with a phases management, General operation basic insulation system for Healthcare facility Department in conditions noise. management MoPHP • Regular maintenance visits Upon the occurrence of any All project Project Maintenance • Checkup on Operational spills, a sufficient quantity phases management, General operation of sand should be poured on Healthcare facility Department in conditions the spilled material, and it management MoPHP • Regular must be completely removed maintenance in bags and disposed visits properly.
Table 7.2 Environmental Monitoring Matrix during Project Operation
Impact˜ Monitoring Monitoring Location˜ Monitoring Frequency of Responsible Indicator˜ Mechanisms˜ Monitoring ˜ Authority˜ Drug and Chemical Healthcare facility Field observation and Weekly ˜ HCF Management Improper handling storage conditions (HCF) reporting, Project Management˜ and storage of Checklist chemicals and drugs Loss of drugs and Healthcare facility˜ Check on quantity and Monthly˜ HCF Management chemicals (HCF) quality and report, Project Management Checklist
HCW management Healthcare facility˜ Reviewing supervision Monthly ˜ HCF Management Improper system in place (HCF) reports, Project Management Management of Observation and field Hazardous Healthcare visits Waste Generated by
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Impact˜ Monitoring Monitoring Location˜ Monitoring Frequency of Responsible Indicator˜ Mechanisms˜ Monitoring ˜ Authority˜ the Project Health Locations of HCW Healthcare facility˜ Observation and field Daily/weekly/monthly˜ HCF Management Facilities handling (HCF) visits
Commitment of HCW Healthcare facility˜ Report non-complying Ongoing follow up and HCF Management management staff (HCF) members monitoring Project Management
Opinion of local Healthcare facility˜ Interviews and Regularly: To be Project Management˜ community (HCF) and surrounding questionnaires identified later community
Failure to return used Healthcare facility˜ Registration of returned After each outreach visit HCF Management Inappropriate healthcare tools (HCF) HCW from outreach Disposal of HCW visits Generated during Opinion of receiving Receiving community Interviews and Regularly: To be Project Management Outreach Activities community questionnaires identified later
Waste management Healthcare facility˜ Review supervision Daily/weekly/monthly HCF Management Mismanagement of system in place (HCF) and surrounding reports, Project Management Increased Quantities community Observation and field of Municipal Solid visits Waste Generated by Locations of municipal Healthcare facility˜ Observation and field Daily/weekly/monthly˜ HCF Management Healthcare Facilities waste handling (HCF) visits Commitment of waste Healthcare facility˜ Report non-complying Ongoing follow up and HCF Management management staff (HCF) members monitoring Project Management
Opinion of local Healthcare facility˜ Interviews and Regularly: To be Project Management˜ community (HCF) surrounding questionnaires identified later community Operation conditions of Healthcare facility˜ Physical observations, On a predetermined, HCF Management Use of Poorly the electric equipment (HCF) Reporting regular basis Project Management Maintained Electric Equipment maintenance Healthcare facility˜ Physical observations, Regularly as needed HCF Management Generators frequency (HCF) Reporting Project Management
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
7.2 Recommendations for Tackling Social Risks and Maximizing Benefits
As noticed from the analysis above, HPP is expected to result in numerous positive social impacts that will benefit women and children who are among the most needy and vulnerable groups in the context of the project.
The recommendations below seek to maximize the social gains through providing some guidelines for implementing activities that aims to ensure:
• Raising communities’ awareness with the importance of using the fixed health facilities to stimulate beneficiaries’ benefit from the fixed health facilities rather than complete dependency on the outreach facilities. • Coordination and communication among various stakeholders Ensure project sustainability
7.2.1 Awareness Raising Programs
It is essential that the project focuses on the implementation of awareness programs and the use of human resources after building their capacities to raise awareness of the beneficiaries in order to change misconceptions and attitudes. This will ensure stimulating local communities’ attention to the importance of using the fixed health facilities to complement for what the outreach services provide. The ESIA has benefited from the available rich experiences in the field and HPP detailed plan include an integrated communication strategy with large components assigned for awareness raising and capacity building. The additional tips provided in the recommendations below are perceived important for strengthening the implementation of the communication strategy. Following are some suggestions for the awareness raising programs:
7.2.1.1 Target Groups
A scarcity of cases where awareness raising measures targeted the husband or the husband's mother (mother-in-law) was observed. As shown by this ESIA, as well as other previous studies, women do not take the prominent role in the decision-making process in matters related to reproduction health, family planning and birth. Thus, other important parties involved in the decision-making process at the household level are currently not targeted and therefore, it is expected that they will continue to cling to their traditionally preferred ideas. It is highly recommended, thus, to target husbands and the mothers of husbands.
The link between family planning and religious beliefs was also observed. Religion is believed to be in opposition to family planning and, accordingly, it is important that awareness raising campaigns target religious leaders first and then get their support for community awareness raising campaigns.
Youth and young couples of pre-marriage age are also a critical category. They are the ones who can change the situation in the future. Raising their awareness will help to break the vicious circle that leads to the continuation of the current situation.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
In addition to the previous groups, the project mainly targets women. A high priority must be given to delivering the message to them.
7.2.1.2 Issues to be Included in the Awareness Raising Programs
Through the literature review that has been carried out during the preparation of the ESIA, it became evident to the consultant that a number of important issues should be tackled by the awareness program. It is proposed, however, to conduct a survey to measure the perceptions and trends. The results of this survey should inform the design of the awareness raising. This survey could be regarded as a needs assessment survey fro the awareness campaigns. The following is an initial list of topics that the consultant perceives as important for the awareness programs:
• The population challenges facing Yemen • Risks related to unattended labor • The culture of reproductive health and education on communicable diseases including STIs, to parents and youth of both sexes • The role of the fixed health facility and the provided services and the importance of these services • Combating misconception • Women’s rights and women’s participation in decision-making • Nutrition and care, of neonatal and children Immunizations and their importance to the child’s health
7.2.1.3 Awareness Raising Tools
It was noted from the interviews that different awareness tools were used by government facilities or donor programs, which greatly take into account the social backgrounds. Written communication forms are presented to educated groups. Video films and television messages were more successful in addressing women, considering the fact that wide portion of women are of illiterate. The previous experience indicated, generally speaking, face to face messages with information providers are the most effective messages and this is in particular applicable to places that are deprived from electricity and do not enjoy easy access to means of media
It is crucial that the selected methods are carefully chosen to fit with the nature of the target groups (age - gender - educational status). Other issues like communities’ preferences to venues and timing should also be taken into consideration62. Dissemination of local success stories is also a favorable tools that promote the message through credible living experience.
7.2.1.4 Providers of Awareness Raising Campaign
In order to make optimum utilization of available human and financial resources, outreach teams should be used in the delivery of awareness programs instead of forming independent teams for this purpose. These teams will be trained on communication skills and awareness campaigns (as
62 It is possible to make use of the available meetings such as visits to health facilities during vaccination times. Qat gatherings can be used as social meetings.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final will be discussed in detail in this chapter). And these teams will be engaged in awareness activities through door to door visits.
Within the project framework attention should be directed to maximizing the impact of the messages through the use of related and influential parties such as religious and tribal leaders. Moreover, local community members with case studies/ success stories are very competitive in delivery these messages.
7.2.1.5 Timeframe for the Implementation of the Awareness Programs
It is planned to start with awareness activities at the early stages of the project and after conducting a research study to measure perceptions and attitudes to identify the needs of the awareness programs. Awareness raising should be treated as an ongoing activity throughout the project cycle.
7.2.1.6 Stakeholders of Relevant to the Awareness Programs
Regarding the proposed organizational structure, the PAU will be the administrative level responsible for the implementation of the various project activities with supervision from the General Department of Family Health. PAU will be hiring a part time Communication Strategy Consultant who will work in developing a comprehensive communication strategy including the awareness activities on the level of the Governorates.
7.2.1.7 Monitoring Awareness Programs
The findings of the proposed perceptions and attitudes survey which is planned to be carried out in the early stages of the project will be the baseline indicators to be measured and monitored in order to assess the impact of the awareness raising campaigns. An interim survey shall be conducted and another survey should also be conducted towards the end of the project. The outreach teams should be encouraged to record their observation and discuss them in monthly and quarterly meetings.
7.2.2 Establishing a System for Participatory Monitoring and Evaluation (PM&E)
Measuring the satisfaction of community members, recipients of the service, is one of the important indicators that should be measured. It is recommended that the current monitoring system that is limited to measuring the completion of activities is changed to a more participatory technique that aims to introduce some of the qualitative tools based on the participation of the beneficiaries. PM&E is different from the conventional M&E system as it engages the beneficiaries in the development of indicators and measurement of the changes. The system is more sensitive to social diversity and different interests and it focuses on measuring the impact on beneficiaries. The system is, in itself, a driving force to empower the target group. This system has special requirements in terms of time and resources. The following is what is meant by Participatory Monitoring and Evaluation (PM&E):
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
- Involvement of beneficiaries in the planning and design service based on their real needs. - Engage the beneficiaries in the development of monitoring indicators - Maximizing the use of local expertise and personal experiences. - Benefit from results to correct the path of activities in case of need thus the assessment is a learning process. Recommending PM&E does not mean excluding all the currently adapted tools. It rather encourages enriching these tools by adding more impact based and qualitative findings.
7.2.2.1 PM&E Tools
Implementing PM&E includes employing several tools that encourage the participation. The most important of these tools are FGDs, in-depth individual interviews and SSI, among other Participatory Rapid Appraisal tools (PRA). These tools aim to come up with in-depth statements that reflect the situation. Statistics and quantitative results support other tools.
7.2.2.2 Indicators of PM&E
As previously noted, the indicators should be identified in the first place with the participation of the beneficiaries, who must express their expectations of the new service. Then indicators should be formulated of in the light of these expectations. However, some indicators such as the initial satisfaction of beneficiaries and visiting rates to the health facility, children infection with diarrhea and gastroenteritis, etc., still remain among of the important indicators that must be monitored. Moreover, the perceptions and attitudes, and the change that will likely occur as a result of awareness raising are also among the important monitoring indicators.
7.2.2. Implementing PM&E
It is proposed the HPP will need to seek consultancy services in order to carry out the PM&E. The Consultant’s ToRs should include capacity building and training for local staff to implement the necessary tools for PM&E. This is seen as a key for the sustainability of the PM&E. This will also help in disseminating the experience in other Governorates locally without the need of external consultant.
7.2.2.4 Timeframe for PM&E
It is proposed that the basic guidelines for the monitoring system be designed during the planning phase of the project. The development of indicators should also be carried out during the same phase. It is proposed to measure the change in the indicators on a quarterly basis. A monitoring report will be issued in the light of an annual review of activities and modification as necessary.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
7.2.3 Strengthening the Fixed Facilities’ Human and Equipment Base
Supporting human resources in health facilities is one of the most important requirements for activating the role of the health facility. The officials interviewed and the health staff have shed light on the human resources requirements, which ranged from the provision of specialists in the hospitals of the districts, to the need for female gynecologists in most health centers. There are many activities that are of procedural nature, which could be adopted by MoPHP to deal with this impact. It is recommended to try to re-distribute the human resources among urban and rural facilities to ensure that the rural population is receiving satisfactory health service. An increase in the number of working hours at health facilities should be considered in order to meet the requirements of the target communities. In the meantime, enhancing the participation of the private sector in the provision of services is also one of the other recommended actions to fill in the health personnel gap63. This could be attained by arranging short term contracts between MoPHP and private doctors.
It should be noted here that the project aims to integrate the methodology of supportive supervision, which the World Health Organization (WHO) encourages. It is emphasized that the role played by supervision in supporting health workers through the promotion of a reciprocal communication process based on interactive learning is extremely important. This methodology will contribute significantly to boosting the project results through the creation of mechanisms for dialogue to overcome obstacles between the project administration employees (especially supervisors in the PAU), and other staff working in outreach services or fixed facilities.
Part of the first component of the project is concerned with supporting the capacities of human resources and enabling them to provide quality services to MNCH. This will be attained through direct training programs and developing guidelines to include new topics that serve the project. It should be noted here the importance of integrating issues of reproductive health and child nutrition to ensure the community midwives and volunteers are qualified to provide these messages to beneficiaries during the awareness visits and in the fixed facility. The midwives indicated that they need to know more about referral services, obstetrics, emergency cases, and care for pregnant women in addition to refresher courses in family planning issues.
Perhaps the Yemeni-German Reproductive Health program is one of the most important models, and well documented initiatives, which should be taken advantage of in preparing the training materials and experiences related to work in the program. Regarding nutrition training programs, the most important previous experience can be found in the community nutrition program funded by UNICEF that is expected to cover 5,300 isolated areas by 2015. There is also the community volunteers program˜64 which is currently funded by the Japanese Agency for International Cooperation (JICA).
63 This recommendation came out during the public consultation by participants from the MoPHP. 64 Community volunteers program is a UNICEF funded program for community nutrition. Reproductive health was then added to the project and the name of the program was changed.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
In addition to proposed technical elements to implement the various components of the project, the consultant proposes some supplementary training topics that should be taken into consideration in the design of training and capacity building programs in order to ensure the optimum implementation of community activities.
Table 7.3 List of Proposed Training Courses to Implement the Social Management Plan
Training Issues Target groups Formation and mobilization of community volunteers PAU teams Training needs assessment for awareness teams PAU
Team building and supportive supervision • General Department of Family Health • General Department of Reproductive Health PAU Communication, negotiation and persuasion skills PAU • The outreach teams Community leaders at the targeted governorates Planning and implementing awareness campaigns • PAU • The outreach teams Health facility staff PM&E and impact monitoring, results monitoring • PAU • The outreach teams Health facility staff Field research skills, PRA (identifying monitoring • PAU indicators – measuring awareness programs needs – The outreach teams measuring willingness to pay) Analyzing qualitative data and writing reports • PAU The outreach teams
It is recommended that capacity-building programs should get out of the traditional scope of lectures and community meetings to a more interactive approach. It is suggested here to take advantage of expertise and successful experiences through organizing exchange visits or seminars to benefit in a more practical manner. The Integrated Management of Childhood Illnesses (IMCI) training model which is an interactive approach applied in an integrated manner under the HSS program is one of the valuable experiences that should be considered in designing the training and capacity building programs.
In addition, there is an urgent need to support the supply of requirements at health facilities. As previously noted, the lack of access to some of the equipment in health facilities is one of the frustrating factors for each of the service providers and service recipients alike. It is expected that part of the project budget will be devoted to the promotion of the development of health facilities and to enabling them to receive referral cases. The needs assessment should be conducted on a case-by-case basis through participation and the consultation with service providers and beneficiaries in each facility. To begin this proposed needs assessment, the ESIA team checked the main requirements of some of the visited health facilities. The following are some examples of the main answers of the health staff in the health facilities about their equipment needs.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Health Center in Gebla District– Ibb Rural Hospital at Salafeya District- Governorate Reimah • Children and adult scales • An operation room. • Blood pressure measuring devices • 50 kg power generator for the whole hospital • Delivery bags • Emergency room • Operating tools • X-rays, compound rays, not working because of a • Diabetes checks malfunction with the battery (cost to fix about 2000 • Ultra sound equipment for pregnant women˜ USD) • Furnishings (blankets - sheets) • Furnishing similar to rural hospitals Transport cars for patients and workers
Salam Hospital – Qaataba – Dal'ea Health Unit in Zofier – Beni Matar • X-ray equipment, dealer, lester District – Sana'a • Vital device – propriety • Ultra sound, x-ray and lab facilities • Lighting for the operating room • Cars for moving patients • Dental unit • Trolley • Trolley • Refrigerator, electricity and gas • Generator • Motorcycle to deliver vaccination services and • PC, fax, copying machine. family planning services (per diem) • Patient stretchers • Scissors, birth bed, emergency bag, pharmaceutical • Incubators library, liquid suction device, waiting chairs Incinerator Stationary for administrative affairs
Wa'lan Rural Hospital – Belad El Oreyb Health Center – Makyras – Rous City – Sana'a Baydah Governorate • Oxygen cylinders • Ambulance A equipped delivery room˜ • X-ray, Ultra sound • Medications to stop bleeding Television and VCR to present awareness Ultra sound device ˜ materials. ˜
7.2.4 Development and Implementation of Coordinating Mechanisms between Relevant Stakeholders
This recommendation comes on the core of the project communication strategy which aims to ensure coordination and avoid duplication of efforts and ensure the best use of resources. It is recommended to draw on the experience of some useful already existing mechanisms such as the Technical Committee in MoPHP in order to exchange experiences, share information, build on positive experiences and avoid and mitigate negative impacts. Activating such a mechanism will ensure coordination of activities and the delivery of funds needed to guarantee that there is no duplication of activities and also to give priority to disadvantaged and remote regions where it is difficult to access health services.
The following is a proposal for the formation of a committee that can fulfill the above mentioned objective.
The preliminary composition of the committee should be as follows:˜ Deputy Primary Health Care Sector Chairman Manager of the project Administration Unit Member Director General of Family Health Department Member Director General of Reproductive Health˜Department Member
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Director General of NCHEI Member Representatives of donors working in the field Members Representatives of NGOs working in the field at the central and governmental levels˜ Members Representatives of the private sector Members Representatives of some of the facilities subject to development at targeted governorates Members Representatives of the Government Executive Bodies (Local Councils) Members Popular Leaders and Tribal Figures Members Religious Leaders Members
Within the framework of activating the role of the committee, a decree must be issued about the formation and the tasks of the committee. This decree should be prepared by the General Department of Family Health in a way that aligns with the developed ESMP. The Committee should meet regularly (preferably on monthly basis). It must be noted that this mechanism would also facilitate the execution of a number of other issues previously mentioned such as awareness campaigns, training and capacity-building and other activities included in the ESMP.˜
7.2.5 Mobilize Financial Resources to Ensure Project Sustainability
MoPHP refered to project sustainability as one of the amin concerns. In all the cases, the outreach program is a routine running program that has annual allocations from the MoPHP’s side. However, currently further mobilizations for funds are underway through dialogue between MoPHP from one side and the Ministry of Finance and the targeted Governorates from the other side. Securing fund for maintaining the outreach activities is a key for project sustainability.
Although project sustainability might be out of the direct scope of the ESIA, the discussion with various consulted groups including various participants in the public consultation showed that fees collection for certain type of services might contribute significantly to the financial sustainability of the project. The consulted stakeholders highlighted that cost sharing is a good way for increasing beneficiaries’ sense with the value of the service
"Easy come, easy go". People take the medicine from the Governmental health facilitates for free and throw it in the garbage bin and go and pay money for medicine prescribed by private doctor."
Dr. Abd El Wahab El Ansi- Yamaan Association for Health and Social Development
In the meantime and in a preliminary attempt to measure the willingness of local communities to pay in return for the improved health service and better referral services at health facilities, the consulted beneficiaries during the ESIA indicated their willingness to pay for a better service. The justification they gave was that they currently do not benefit from the public service, thus they alternatively either turn to the private sector which is of a higher cost or ignore the issue or use only informal assistance from relatives, friends or other non trained midwives (for deliveries). Some of the interviewees said that they prefer to pay additional fees rather than paying much more cost to handle the complications in cases of negligence.
˘We are ready to pay the required fees for all sorts of examinations by specialists or more specifically by a female specialists. We pay for the x- rays YR 600 R and for the C-section operation about YR 50000 or YR 60000 at the private sector and so on.˘ Newly wedded wives – El Bydaa governorate And public service providers – Makiras District– El Bydaa' governorate
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
"If the facility is improved and the services are available we are ready to pay similar to other neighboring health facilities for lab analysis such as diabetes test or albumin which costs about YR 300 R in public hospitals and family planning fees such as YR 250R for pills, and YR 2000 for birth, vaccination is for free in the facility and at all governorates." An interview with 40 years old women or more – El Bydaa governorate and newly wedded women – Sofleya District– Reimah governorate "Yes, we will be willing to pay the appropriate, reasonable or affordable fee based on the availability of the required services." newly married women - Qattbah District – Al Dahla'a
However, the ESIA team recogizes the social sensitivity of this recommendation and the fact that the poverty conditions of GoY should not be underestimated. In this regard, further future participatory consultation is required to measure community willingness to pay and their affordability and the types of services that might be offered in return for service fess.
7.3 Organizational Structure for Implementing HPP
As noted in Chapter 6 concerning project alternatives, it is recommended to form an independent PAU for the project to operate under the direct supervision of the General Department of Family Health (GDFH) in cooperation with other relevant departments. The GDFH will be responsible for: • Day to day project management activities • Facilitating coordination between the Outreach Team and the PAU. • The Head of the GDFH will act as the Project Manager and will be responsible for the overall project management.
HPP is planning to establish a PAU to optimize the implementation of the project through coordination with the concerned departments under their full supervision. According to the PAD, the main objective of forming the PAU is to: • Assist the Outreach Team in project implementation, in accordance with the legal agreement and manage the resources of the project; • Facilitate efforts to conduct the mapping and baseline survey, monitor and evaluate the project targets, and evaluate the project results in coordination with the Outreach Team; • Handle procurement, financial, and disbursement management, including the preparation of withdrawal applications under the project; • Ensure that an independent audit of the project is carried out on an annual basis, • Prepare the financial and procurement sections of the quarterly Progress Reports and consolidate with the technical sections prepared by the Outreach Team for submission to the SC and IDA; • Act as liaison between the Outreach Team/ GDFH (General Director of Family Health) and IDA • Ensure that all reporting requirements for IDA are met in accordance with the project legal agreement; and • Provide secretarial services to facilitate the activities of the SC.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
In addition to the above tasks the ESIA team recommends the PAU responsibilities to include the following: • Emphasis on the implementation of all proposed activities in the ESMP through hiring consultants (environmental consultant and communication strategy consultant). • Coordination with relevant parties on the local, executive and community levels to choose the outreach teams. • Activation of the system of "supportive supervision" through the training of the Governorate teams to activate the system. • Taking advantage of the project preparatory phase, planned to last for a duration of about 18- 24 months in which lessons should be drawn from experiences and practices, to come up with a supportive vision to implement the project in the most efficient possible way. • Cooperating with the consultants to facilitate their tasks and take advantage of their experience in order to integrate it in the project areas. • Monitoring of the development and implementation of training programs for the project • The staff selected to work in PAU are required to have, in addition to experience in various specialization areas, experience in the field of mother and children’s health and familiarity with the situation and the challenges facing Yemen in this field. They should also be aware of the program and other projects implemented in these areas. Women should be encouraged to participate in these posts. Figure 7.4 visualize the recommended structure for the PAU.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Figure 7.4 The Recommended Organizational Structure for PAU of the Health and Population Project
Choosing field teams Project Administration Unit (PAU) HPP (under direct supervision of the General Department of
Family Health) Supportive supervision Central level Regular ƒProject Manager reports Capacity building Delivering the opinion of the M&E beneficiaries
Benefiting from all experiences
Consultation
Project focal point at target governorates Governorate level
Field Supervisors (Supervisor for each Directorate directorate) level
Outreach teams each team headed by a Village level / Supervisor remote areas
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
7.4 Environmental and Social Management Plan (ESMP) Budget 65
Table 7.4 Proposed Budgets for the ESMP
Item Estimated Budget USD • An external consultant to study and recommend guidelines for the developing of a proper system for managing hazardous healthcare waste at the project health facilities
• An external consultant for the design and implementation of five training courses concerning the implementation and management of a system for 90,000 handling hazardous healthcare waste for midwives and medical outreach teams personnel • Consultant to conduct ongoing assessment of the environmental situation and monitoring of the environmental compatibility of the project activities in 6 governorates twice a year (1000/round) Design and implementation of a program to educate and raise 8,000 the efficiency of environmental measures Designing a training program about environmental inspection 3,000 for the project activities TOTAL 101,000
65 Items such as furnishings for offices, salaries, incentives for community volunteers over the course of four years, training and capacity building were not included in this budget because it is assumed that funds have already been allocated for these items
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
8. Consultations with Stakeholders
Within the preparation of the framework for the draft study (as already noted in Chapter 1 of this report), many field interviews were conducted to consult with stakeholders and to integrate their views and aspirations related to the project in the draft study. Consulting with stakeholders is an ongoing process. Interviews are still underway after the delivery of the draft report and a public consultation is also being planned to present the results of the draft ESIA.
8.1 The Most Important Results from Meetings with Stakeholders during the Study of the Current Situation
Many elements of the data represented in the previous chapters of the study are the result of consultation with stakeholders. As noted in the presentation, reference was made to the data source, whether primary or secondary, in addition to noting and identifying the social groups that provided the different views in order to highlight the diversity of views among various target groups. In general, the most important results that have been reached through meetings with stakeholders are:
ƒThe nature of the culture and geography poses many challenges to the status quo related to the health of the mother and child.
ƒWomen at the target areas, often, are not satisfied with the current situation. The frequency of deliveries and poor reproductive health care lead to negative impacts on their health, their family life and their ability to work.
ƒThe level of awareness about the role of vaccination for the safety of children is relatively high. However, the awareness of issues related to child nutrition is low. Poverty can make the situation more challenging because it affects the quality of food for the whole family including the child. Some cultural and social constraints such as the widespread use of Qat also indirectly affect the food availability in homes.
ƒThe level of awareness and persuasion of the importance of family planning remains low, especially in remote areas. The majority of rural women give birth to a large number of children, but some slightly positive change has been observed in newer generations.
ƒThe lack of equipment and personnel at fixed facilities prevents the effective delivery of service to the targets and weakens the interest and desire of women to visit the health facility because they believe that their visit will be useless in many cases.
ƒThe project is well received by various groups, especially in areas suffering from a lack of health facilities, poor service or lack of qualified personnel.
ƒMost of the predicted impacts by the consulted community members were positive on the health and the awareness of women and children.
ƒTargets and the health facilities staff did not express any potential negative impacts. The reported negative impacts in the study are in fact a set of concerns which must be dealt with through procedures that aim to maximize the social benefits.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
8.2 Important Findings from the Public Consultation
After drafting the ESIA report for the HPP, a Public Consultation event was organized on the 6th of June, 2010 in the Ministry of Public Health and Population (MoPHP), Sana’a, Yemen. Annex 3 of this report presents the documentation package from the Public Consultation. The event had the primary interest of engaging a wider range of relevant stakeholders and disclosing the EIA preliminary results to a wider audience. In order to attain these objective, Public Consultation invitations were handed to stakeholders of relevance to the project both on the central and Governorates level. A sample of the sent invitation is attached in Annex 3-A. Invitations have been distributed to stakeholders of relevance to the project along with a non-technical executive summary for the ESIA and the Public consultation agenda. The group of invitees included governmental personnel, NGOs, civil society, press and the public in general. A list of participants in the consultation is attached in Annex 3-B, and the scanned registration form is attached in Annex 3-C. The main objective of the Public Consultation was to review the findings of the EIA including the identified impacts and the proposed mitigation measures under the ESMP. The participants’ feedback was meant to inform the final version of the ESIA report through full consideration of the relevant comments.
The Public Consultation was divided into two main sessions (according to the agenda attached in Annex 3-D). The first involved welcome speeches by Dr. Majed Al Janeed, Deputy Minster of Primary Health Care sector and Dr. Ali Al Medwahi, General Director of the Family Health Sector, MoPHP, who welcomed participants, thanked them for participating and shed light on the importance of the HPP and its relevance to the national strategy in addressing health challenges. This was followed by an introductory presentation on the HPP project objectives, scope, geographic target and main components. This presentation was given by Dr. Abdel Hakem Al Kohlani, Director General of Disease Control and Surveillance Department, MoPHP. The same session included a presentation of the social part of the ESIA. The presentation included the following main key components:
• Baseline information and general indicators related to the health of the mother and child • Predicted social impacts during the preparation and implementation phases • Project alternatives • Social mitigation and monitoring plan
This social presentation was the end of the first session of the Public Consultation. The second session included the presentation of the findings of the environmental aspects related to the ESIA including:
• Baseline information and general indicators related to biodiversity and the environment in the targeted Governorates • Predicted environmental impacts during the preparation and implementation phases • Environmental mitigation and monitoring plan
This presentation was followed, in the same second session, by an open discussion where all participants were invited to present their comments and feedback on the presented information.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
During this session, the concerned stakeholders from governmental authorities (including the MoPHP and the Environmental Protection Agency) as well as the team of consultants provided replies to the issues raised. In order to ensure efficient documentation of the participants’ feedback, several tools were employed. This mainly include direct note taking by the EcoConServ consulting team and their local partner. In addition, comment sheets were distributed to the Public Consultation participants to ensure that comments of the widest portion possible of participants are taken into account. (A sample of the written feedback sheet is attached in Annex 3-E).
Figure 8-1 Speakers at the Public Figure 8-2 Presenting HPP Background Consultation and Description
Participants’ questions were replied to by the consultants. Several raised issues are already included in the full ESIA draft report while other relevant comments and feedback have been incorporated into this final version of the report. Participants were invited to access the full ESIA report by contacting the Family Health Sector in MoPHP. The following section of this chapter presents the most important feedback received and the replies that were provided to participants during the Public Consultation.
Figure 8-3 Participant contribution during Figure 8-4 Participant contribution during the open discussion session the open discussion session
In general, from an environmental perspective, it is important to highlight the lack of awareness of the audience on the expectations and roles of the ESIA in general.
In addition, the audience focused on the general environmental problems of the health sector in Yemen and not the environmental impacts of the HPP specifically.
Both issues were addressed and explained thoroughly several times throughout the meeting by EcoConServ and by the representative of the Environmental Protection Agency (EPA)
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
However, the audience emphasized the dangers and risks caused by the healthcare waste generation, mismanagement and uncontrolled disposal.
The issue of a lack of financial allocations for healthcare waste management and safe disposal in general was emphasized. A recommendation was given to the project’s administration to allocate sufficient funds to this issue.
One comment mentioned that the HPP could be considered as one of the cleanest projects from an environmental point of view.
There was confusion about the situation of Aden and the expected construction activities to be carried out. MoPHP representative cleared up the confusion and stated firmly that no construction activities of any kind are envisioned to date.
The rest of the audience’s suggestions, comments and main focus were attributed to different aspects related to healthcare waste issues.
In general, the project’s environmental aspects were accepted by the audience and no major remarks concerning the findings or the expected impacts were raised by the audience.
A table summarizing most of the received environmental comments is also attached to the report in Annex 3-E
From the social perspective, the project agreed to tackle one of the main challenges in the health sector in Yemen, namely the issue of women and children’s access to health facilities and the various topographic, cultural and demographic challenges associated with this subject. The project was agreed to be designed to handle several root causes of the problem.
Participants, generally, received the social impact analysis very well and appreciated, in particular, the discussion around the potential risks related to project sustainability. The discussion around cost sharing was also very informative.
Main Comments and Feedbacks Raised by Participants in the Public Hearing
Dr. Qaed Mohammad Obadi, Health Policies Unit Consultant The ESIA findings are very useful and informative. I recommend calling the ESMP as recommendations rather than plan because the plan should include timeframes and roles distributions.
We wished also to hear more about how people perceive the current services and their views on how quality could be improved.
Reply by EcoConServ Consultant: The team can confidently claim that the ESMP include a proper management plan with timeframes and roles distribution. Although this could not be presented in details in the event, these are included in the ESIA.
Most of the presented findings are actually people’s views. The ESIA preparation involved a participatory exercise and most of the qualitative findings are the outcome of consulting with local community members.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Dr. Nabeha El Abhar, Curative Care Sector This project is supposed to be one of the "cleanest" since it is largely outreach service. Some of the social survey tools have limitations like the FGD where the opinion of one of the participant can easily affect others’ opinions. There is a sever shortage in human resources in the fixed health facilities in certain districts, as shown by the ESIA. This is recommended to be addressed through contracts between the MoPHP and the private sector.
Reply by EcoConServ Consultant: All the tools have their own strengths and weaknesses. Our selection for the tools was made on the light of the various allowed resources. Although we agree on the limitations, we still believe in the importance of qualitative tools and the value they add to the findings of this ESIA. Limitations are included in the methodology chapter.
The point of the involvement of the private sector is a very important point that will be incorporated in the ESIA.
Dr. Abdel Rahman Hamad, Director General of Private Health Facilities
The individual share of health expenditures has not been practically increased as shown by the study. The value of Yemeni Riyal has drastically been reduced compare to the USD.
Reply by EcoConServ Consultant: This point will be considered in the final version of the ESIA.
Dr. Kamal Moustafa, The World Health Organization
The recommendations of the study put the ball on the MoPHP’s court and it is the ministry’s turn to react. Considering the demographic conditions of the country, outreach services are inevitable since they are the most appropriate type of services. However, as the ESIA findings showed, what’s after the project? Sustainability is a big concern. Is it possible when we reach 2016 to return back to the baseline of 2010? I am with the principle of "the cost sharing" as presented by the ESIA alternatives. A questionnaire to assess people willingness to pay is recommended and the service providers in rural areas are very knowledgeable about the economic conditions of various families. The poorest could be exempted from the cost sharing.
Reply by EcoConServ Consultant: The ESIA has recommended the alternative of cost sharing for certain types of service packages. However, this recommendation has been made very cautiously due to the sensitivities related to the poorest families’ inability to afford for service fees. However, it should be noted that people’s willingness to pay for better level of services has been initially assessed as part of the ESIA. Local communities’ views were that they are currently paying anyway for the private sector to fill in the gap of the unavailability of quality Governmental services. They showed willingness to pay as they currently do. A more detailed WTP survey has been recommended as part of the ESMP.
Dr. Somaya Al Ared, Family Care NGO I see the recommendations as doable and practical. I agree on the alternative of cost sharing from the experience of our NGO. Outreach services should be provided for free while other packaged should be provided against service fees. This is critical for sustainability.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Dr. Abd El Wahab El Ansi, Yamaan Association for Health and Social Development
Qat is a crucial problem that no reference was made to. Smoking also is a big threat. Regarding the cost sharing option, I believe that "easy come, easy go". Unless people pay for the service, they will never sense its value. I claim that Yemen poverty is more a "behavioral poverty". Families spend on qat and smoking much more than what they spend on health service.
Eng. Salem Abdallah, Head of the Environmental Monitoring EPA The comments of participants’ showed that their expectations from the ESIA go far beyond the actual scope of work of these studies. EIA is only meant to measure the predicted impacts on the environmental aspects from a specific project within a specific activities outline. The presented ESIA is very comprehensive. We only recommend the need for raising awareness on various levels including the central level. Financial challenges are not the only problem and the main source of solutions. However, there are further challenges in awareness and implementation mechanisms as well as coordination between concerned authorities and stakeholders.
Ms Fayza Ahmed, Al Shahbaa NGO, Manakha The experience of local NGOs and their knowledge about the economic conditions and poverty issues should be utilized in targeting the poorest families. We also have our tools to point them.
Reply by EcoConServ Consultant: this is an important point that will be considered in the final ESIA report.
Dr. Ali Al Modwahi, General Director of the Family Health Dept. MoPHP
The project is sustainable, anyway, and is not a new type of project for the MoPHP. We have major component of outreach with annual allocation reach YR 135 million. Thus the project is running anyway and there is no fear from the lack of sustainability.
Considering poverty targeting under the third alternative of cost sharing has some sensitivities. The issue of selecting who to pay and who to be exempted is problematic. The preferable option is to get the support form Local Councils and other relevant ministries rather that imposing service fees on local communities. It should be noted that access to health services is a pure right for children that should be provided for free by State.
The project will involve large cooperation among various donors, the MoPHP and the WB. The mentioned fund of USD 28 million is only the WB contribution. MoPHP is contributing with around USD 30 millions in the form of vaccinations, outreach teams costs …etc. International donors like WHO and UNICEF will also contribute with food and other complementary supplies.
As part of the disclosure of the ESIA results, the press covered the event. The news about the Public Consultation as presented in Al Thawra Newspaper, on the 7th of June, 2010 was scanned and attached in Annex 3-F.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Conclusion˜
The planned Health and Population Project which is to be implemented by the Ministry of Public Health and Population in Yemen is a feasible project from both the environmental and social prospective. It is predicted that the project will contribute to harvest many of the social and environmental benefits to the population, especially for women and children. The negative environmental and social impacts can be handled using the mitigation measures proposed by the ESIA.
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
References
The Yemen Family health survey, 2003, Pan Arabic Project for Family Health Country Cooperation Strategy for WHO and the Republic of Yemen, 2002-2007 ILO and the Government of Yemen Cooperation Strategy, 2007 Poverty Reduction Strategy, World Bank, 2003-2005 Yemen Men and Women in statistics, CSO and Oxfam, 2007 Yemen National Health Strategy 2009-2015: Towards Quality, Equitable health Services, Draft, MoPHP, 2009 Final Census Results, Demographic Analysis, CSO, 2006 Social Analysis, World Bank, 2006 Yemen Health Analyzer (software), MoPHP and USAID, 2008 The Environmental and Social Impact Assessment (ESIA), Rural Energy Access Project (REAP), EcoConServ, 2009 Yemen Health Sector Auditing Report, First Phase, Analysis for the Current Situation, MoPHP, 2008 Millennium Development Goals, Needs Assessment, Yemen Country Report, September, 2005 Poverty Assessment, Yemen, UNDP, 2007 Yemen Common Country Assessment, UN and WHO, 2005 Perceptions and Realities, Yemeni Men and Women and Contraception, Mary Stopes, 2007 Healthy Timing and Spacing of Pregnancy (HTSP) in Yemen, USAID (undated reference) Women Role in Local Economic in Aden, Yemen, World Bank, 2005
Websites http://www.yementimes.com/DefaultDET.aspx?i=1230&p=health&a=1 http://www.esdproj.org/site/DocServer/HTSP_Brief_Yemen.pdf?docID=844 http://www.un.org/arabic/esa/rbas/MDGŽ http://www.yg-rhp.orgŽ http://www.yemen-nic.info/index.php http://daccess-dds-ny.un.org/doc/UNDOC/GEN/N07/278/33/PDF/N0727833.pdf?OpenElement http://www.arab-hdr.org/publications/other/undp/mdgr/yemen-nmdgr-05e.pdf http://www.mariestopes.org/documents/publications/Perceptions_and_realities_full_report_low_res.pdf
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Annex 1: List of Consulted Stakeholders
Representatives from the Ministry of Public Health and Population (MoPHP)
Name Position 1. ˜Dr. Gamal Thabet Nasher Undersecretary of the Planning Sector, MoPHP 2. ˜˜˜Dr. Fawzy Hamed Gaafar Head of the Grant Unit, MoPHP 3. Dr. Aly Ahmed El Director of the General Department of Family health, Medwahy MoPHP 4. Dr. Moslah El Tawaly Director of the Health Planning, MoPHP 5. Dr. Mohamed Mothany Environmental Health Coordinator, MoPHP Salem 6. Dr. Gamal Sadkan Head of the Department of Reproductive Health, Sana’a Heath Office 7. Eng.Nasr Hassan El National Center for Health Education and Information, Absy MopHP 8. Dr. Ahmed Mohamed Health Policies and Technical Support Unit, MoPHP Aklan 9. Dr. Nabiha Abd El Director of the General Department of Reproductive ˜Rahman El Abhar Health, MoPHP 10. Dr. Abd El Gabar Aly Director of the Information Centre, MoPHP ˜Elghythe 11. Ms. Samira Taher Department of Reproductive Health, MoPHP
Representatives from the Health Facilities
Waalan Rural Hospital, Belad El Rous, Sana’a Name˜ Position ˜ 12. Fackha Abd Allah Health Worker Mohamed Abd Allah ˜ 13. Fatma Mohamed Hussin Midwife ˜ El Harawy ˜ 14. Ashwak Aly Mohamed Administrative 15. Fatma Ahmed Yahya˜ Assistant Staff Sayan Health Center, Sana’a Name Position ˜ 16. Dr. Nesem El Sabry Doctor˜ 17. Asmhan Abd El Khalek ˜ Midwife ˜ Mohammad El Dorra Hospital, Gahana District, Sana’a Name ˜ Position ˜ 18. Dr. Omyda Bekofa Doctor 19. Wahbya El zamary˜ Midwife ˜ 20. Nadia Hamam Midwife 21. Nagia El Bashary Midwife 22. Gamila El Dasem Midwife 23. Aziz Dawd˜ Midwife 24. Aml El Dasm Midwife 25. Fatma Mallak Midwife Al Zafer Health Unit, Bani Matar District, Sana’a Name ˜ Position ˜
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
26. Somya Abd El Khalek Health Worker 27. Mubrouk Abd Allah Doctor Assistant The Rural Hospital, Soflya District, Reimah Governorate Name ˜ Position ˜ 28. Dr. Yahya Abdo Morad Hospital Manager 29. El Azy Abdo El Deputy Manager Montaser 30. Dr. Lyzy Mohamed Doctor Awad 31. Saad Mohamed El Doctor Assistant ˜ Karasany 32. Talal Hedar Hassan Lab Analyzer 33. Amna Sanan Aly El Midwife Montasr 34. Takwa Abd Allah El Midwife Montaser 35. Dr. Abd El Kuder Doctor Ahmed 36. Khaled Ahmed El Sayfy Nurse 37. Abdo Mohsan El hosny Nurse 38. Aly Mohamed Aly Nurse 39. Khaled Omar El Dars Pharmacist 40. Amar Abdo Aly Saad Scan Specialist 41. Morad Aly Mohamed Nurse 42. Mohamed Abd El Health worker Rahman Salah 43. Boushra Yahya Ahmed Midwife 44. Ahmed Kaad Abdo Guard 45. Omar Mohsan El Mosna Guard
46. Hashem Mohamed El Guard Washly 47. Abd Elwahed Abd El rahman El Soufi Gabla Health Centre, Ibb Governorate Name ˜ Position ˜ 48. Dr. Hussen Deif Allah Head of the Health Centre 49. Shams Said Kahtan Doctor 50. Yasmie Abd El Khateb Head of the Materal Health 51. Hana Mohamed El fekya Midwife 52. Eman Abd Elrhman Midwife Elzeraky 53. Gawhra Gamal Elden Midwife 54. Sahar Yahya El Mosnf Nurse 55. Haya Aly Mohsan Nurse 56. Yahiya Abd Elrahman El Midwife sakaf 57. Abd Elghany Pharmacist 58. Abd Elsamd Elwase Elsa Lab Analyzer 59. Mohamed Hamoud El Lab Analyzer
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
khoulany 60. Abd Elsamad Ismail Lab Analyzer 61. Mohamed Elwan Nurse Elmorsy 62. Ahmed Aly Elsada Nurse 63. Mousa Aly Abd Allah El Health Worker kasya 64. Abd El Rakeb Shamsan Administrative 65. Aly Aly El Sadat Guard 66. Fathy Yahia Mohamed Administrative El Salam Hospital, Koatoba District, Al Dala’a Governorate Name Position 67. Abd El Gabar Saleh Hospital Manager Areshan 68. Gamel elboudki Doctor 69. Samir Hamoud ˜ Lab Specialist 70. Yasmin El gaashy Health Worker 71. Entsar Said Health Worker 72. Hanan Mohamed El Health Worker 73. Abd Elkawy Mohsan Vaccination Specialist 74. Mona Ahmed Saleh Health Worker Oreb Health Centre, Makeras District, Al Baydah Name Position 75. Afrah Abd Allah Naser Midwife 76. Zeinb El khedr Aly Midwife 77. Liza Hussyn El Manae Midwife 78. Soad Hussen El Borkany Midwife 79. Aziza El Khadr El Midwife Kotshe 80. Mohsan Mohamed Saleh Nurse 81. Saleh Awad E Mosakay Lab Analyzer 82. Saleh Salem El Nuzaf Nurse 83. Saleh Salem Atef Doctor 84. Ahmed Saleh Farhan Nurse 85. Abd El Rahman Ahmed Nurse Abbas
Non-Governmental Service Providers
Dr. Atroush Clinic – Al Baydah 1. Mounira Kadre Midwife 2. Ekhlas Aly Midwife 3. Saad Hedya Lab Analyzer 4. Soma Pharmacist 5. Dr. Hassan Gaber Doctor 6. Dt. Nagory Doctor 7. Zeinb Ibrahim Assistant Staff 8. Naser Aly Assistant Staff Family Care Association, Sana’a 9. Ebtisam Elkabsy Doctor
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
10. Amaa El Rahman Gahaf Nurse 11. Zaafran El Shawafy Nurse 12. Sena Secretary
Beneficiaries from Health Service Facilities
Waalan Rural Hospital, Belad El Rous, Sana’a 1. Nagia Abd Allah The Rural Hospital, Soflya District, Reimah Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final Governorate Women in their twenties
Kafya Mohamed Abd Allah 2. Kefaya Mohamed Aly 3. Asrya Mohamed Aly 4. Warda ahmed El Hosany 5. Amira El Aze 6. Warda Ahmed Aly 7. Asrya Abd Allah El Montser 8. Amna Saleh Mohamed 9. Women in their forties
10. Gamila Hassan Abdo Sabah Mohamed Aly 11. 12. Suada Abd Allah Aly Amna Saleh El Hag 13. 14. Mariam Mohamed Aly 15. Gamila Abdo Megahed 16. Hamama Mohamed Abd Allah 17. Fawzya Hamouda Gabla Health Centre, Ibb Governorate Women in their twenties 18. Asma Abd El Salam 19. Yasmin Mohamed Aklan 20. Haya Aly Mohsen 21. Nada Naser El Karaba 22. Nagwa Hassan Aly 23. Hoda Thabet Abdo Women in their forties 24. Anisa Hasan Abd El Gabar 25. Fatma Abdo Molhe 26. Ghanya Said Hemad 27. Khadiga Ahmed Aly 28. Hassan Ahmed Molhe 29. Fakhraya Abdo Aly 30. Wahyba Aly Himad 31. Gamila Aly El Sayer Al Ares, Bani Matar District, Sana’a Women in their twenties 32. Sabah Aly Mahdy 33. Aml Abd Allah Mohamed 34. Gamila Abd Allah Kasem 35. Afrah Yahiya Kokabany 36. Gamila Mohamed Saleh 37. Ahlam Kasem Mohamed El38. Salam Fatma Hospital, Mohamed Koatoba Ismail District , Al Dala’a Governorate39. Sabrya Aly Al Ares, Bani Matar District, Sana’a Women in their twenties Women in their forties 56. Belkas Mohamed Saleh 57.40. AsmaaWafaa MohamedKhaled Ahmed Mohamed 58.41. BoushraMahdya HassanMohamed El Hushly 59.42. FathyaFatma HamoudAly Saleh 60.43. HodaHind MansourMohamed Mohsen 61.44. SabrenWarda SalehMohamed Ahmed Abd Allah Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Interviews Mothers-in-law
Soflya District, Reimah Governorate
1. Nagat Ahmed Kaad Saada Abdo Hemed 2. 3. Warda Abd Allah Hassan Fatma Ahmed Ragab 4. 5. Saada Hemad Abd Allah Mariam Ahmed El Nagar 6. 7. Fatma Aly Gara Zobada Mohamed El Montaser 8. Gabla District, Ibb Governorate
9. Badrya kaad El helya
10. Mesk Aly El Sheray
11. Loza Abdo Mohamed
12. Tahany Hamid
13. Barod Hamod Abas
14. Fawzya Abdo Gamal El Deen
15. Zeinb Aly Moslah
16. Saoud Aly Mohamed
Al Ares, Bani Matar District, Sana’a
17. Warda Nagi Aly 18. Takia Saleh Abd Allah
19. Nabila Saleh Abd Allah 20. Warda Yahiya El dalae
21. Saada Naser Ahmed Aly 22. Thabta Mohsn
23. Fatma Ahmed Aly 24. Warda saleh Al Aromy
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Koatoba District, Al Dala’a Governorate 25. Mariam Kaed Hadi
26. Kobol Mohamed
27. Mariam Mohamed Abd Allah 28. Mohsana Hussein Aly 29. Sayda Mohamed Taha
30. Bedor El reme
31. Amna Barke
Makeras District, Al Baydah 32. Hafsa Abd Allah Saleh
33. Khazam Abdo Hamod 34. Shafika Abd El Rab
35. Khadiga Hamod 36. Hind Hazaa Men Interviews
37. Warda Abdo Aly 38. Sabah Hael Ahmed 39. Mariam Aly Farhan
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Soflya District, Reimah Governorate
1. Omar Mohsan El Hosny 2. Talal Hedar Hassan 3. El Azy Abdo Yahia 4. Ahmed Saleh Gabla District, Ibb Governorate Mohammad Mohammad Gebary 5. Ali Abdel razak El Maten 6. Abdel hakem Ahmed 7. Adel Abdel Razek 8. Mohammad Abdu El Khayat Al Ares, Bani Matar District, Sana’a 9. Moen Abdallah Kase 10. Ibrahim Ali El Hamdany 11. Mohammad Yehya El haba 12. Adel Ahmed El Hemdany 13. Mohammad Kasem 14. Ali Houssein Hashtam Koatoba District, Al Dala’a Governorate 15. Abdullah Mohammad
16. Saleh Muthanna Saleh 17. Abdel Daeyem Saad Saleh 18. Hassan Housin 19. Mohammad Mohsen Housien Makeras District, Al Baydah 20. Ahmed Saleh Ahmed Farhan 21. Adel Rahman Ahmed Abas 22. Saleh Awad 23. Saleh Ahmed El Sayed 24. Mohammad Mousaad 25. Abdaollah Abdeollah El Houbeshi 26. Ali Ghaleb
Health and Population Project (HPP), Yemen Environmental and Social Impact Assessment (ESIA)-Final
Annex 2: Guidelines for Healthcare Waste Management at Healthcare Centers and Facilities
Introduction: Guidelines and Code of Practice
Definition of the Guidelines and Code of Practice
This is a group of instructions for handling all types of solid waste, generated due to the provision of healthcare activities and services in both urban and rural healthcare facilities, albeit inside or outside its premises.
These guidelines and Code of practice is a comprehensive guidance for all relevant practices of HCWM in urban and rural health facilities for the Health Sector. It describes the principles of healthcare waste management (HCWM); and defines all types and different classification of solid waste, provisions and instructions of their handling. The Code, acts as detailed statute, governing HCW management system in different health facilities.
However, these guidelines and code of practice could be considered as an updatable effort.
Whenever necessary, a full fledged "Guidance and Code of practice" must be prepared for the organization of a healthcare waste management for the special sections and departments such as laboratories, blood banks, gynecology and obstetrics and x-ray treatment and diagnosis units. In all cases, all documents must be prepared by the same rules of these guidelines and Code.
Goals of Guidelines and Code of Practice
ƒ Guiding all healthcare teams, operators and practitioners in urban and rural healthcare facilities in HCW management; and handling of healthcare wastes inside and outside healthcare facilities for fulfillment of occupational, health, and environmental safety requirements. ƒ Provision of integrated safety procedures to ensure the proper compliance with waste management provisions and measures.
Limits of the Application of the Guidelines and Code of Practice
These guidelines cover healthcare wastes only and are applied on all urban and rural healthcare facilities, under the responsibility and control of relevant healthcare departments.
Content of the Guidelines and Code of Practice
Apart from this introduction, the current guidelines include two chapters discussing and detailing the following elements:-
ƒ Definition, sources and types of healthcare Waste (HCW) ƒ Personal/health and environmental dangers of HCW ƒ Actions and practices of HCWM in urban and rural healthcare facilities under the agreed upon system. ƒ Responsibilities and Duties of HCWM: - Separation and sorting of healthcare waste. - Packing and packaging of HCW - Collection of HCW - Storage of HCW at the health facility level. - On site transport of HCW - Transport of HCW outside health facilities (off site transport) - Treatment of HCW
ƒ Measures of handling emergency cases ƒ Recording, registration and documentation
List of Prospective Officials Having the Guidelines and Code of Practice
The following, but not limited to, officials must be aware and maintain an updated written copy of these guidelines:
ƒ Managers of healthcare Facilities; ƒ Chiefs or heads of nursing departments; ƒ Officials of infection control committees; ƒ Managers of laboratories and blood banks in or outside the healthcare ; and ƒ Managers of final collection and treatment stations (which may include incineration and autoclaving equipment).
The executive unit of the management system must provide a copy of the guidelines and code of practice and ensure their easy accessibility, whenever necessary, to their staff and/or at least keep them fully familiar and aware of its content.
Chapter 1: Handling of Healthcare Wastes
I: Definition and Sources of Healthcare Waste:
Healthcare wastes are defined as a group of wastes; generated by healthcare activities and the healthcare is defined as medical activities which include diagnosis, treatment, monitoring in addition to prevention activities and reducing incapacity problems and complications for human beings and animals as well as research & studies, conducted under the supervision of medical, dental and veterinary practitioners.
Sources of Healthcare Waste Generation
The main source of healthcare wastes are the Healthcare facilities of all levels affiliated to the health sector. This includes:
1- Hospitals
- Public Hospitals: providing widespread medical services - Specialized Hospitals: including fever, chest, leprosy, skin diseases in addition to other specialties like orthopedics, Pediatrics, Gynecology and Obstetrics, Ophthalmology.
2- Public and Specialized Primary healthcare Clinics and Centers, including: - Clinics and centers of primary health care; - Clinics and centers of school health care; - Maternal and childhood healthcare units; - Family planning units; - Endemic patients care centers.
3- Other health facilities like: - Sanatoriums and recovery centers;
- Comprehensive clinics and dispensaries; - Laboratories; - Dental clinics; - Pharmacies & drug stores; - Ambulance & Emergency centers; - Medical research & Study centers; - Veterinary clinics; - Livestock & sheep farms (needles, syringes and pharmaceutical products)
II: Types (sections) of Healthcare Waste
As concerns all healthcare facilities, the types of generated waste must be defined and classified as healthcare waste as follows:-
ƒ Hazardous wastes, including: - Infectious waste; - Needles and sharp objects; - Pathogenic or pathological waste (disposed parts of human organs and tissues); - Harmful chemical waste; - Pharmaceutical waste; - Radioactive waste;
ƒ General (municipal) solid waste - Paper; - Plastic waste; - Food; - Metal; - Glass…etc.
Following are some detailed definitions and concepts of healthcare waste types.
1. Hazardous Healthcare Waste
Infectious Wastes
All wastes, having or suspect of having pathogens (like bacteria, viruses, fungi or other parasites) in concentrations and amounts which may cause diseases in target organs , including : - Cultures and materials carrying infectious elements in laboratories or due to surgeries or of infected patients (like blood soaked materials and machines); - Wastes of isolated patients (like feces, dressing of infected wounds, blood or any biological liquid stained clothes); - Wastes, having been touched by infected patients; treated by dialysis equipment like tubes and filters, disposable napkins aprons and gloves…etc. - Infected laboratories research animals or suspect of having infection; - Any plates, containers and/or lab materials having been touched by infected persons or animals; and/or used for analysis of infected organic substance.
Needles and Sharp Objects
They include all needles and sharp and punching materials, such as syringes, bleeding blades, intravenous and blood vessel injections, pieces of saws, knives, blades, scalpels as well as broken glass and nails and any similar materials used for and/or can cause skin punching or cutting. All those sharp objects may include substances which are or suspect of being infectious. This also includes all sharp tools or materials whose cleanliness is questionable and thus causing infection. All infectious or to be infectious wastes and sharp objects (whether infectious or not) can be classified as hazardous HCW. In case, the nature of waste under consideration is questionable they must be considered hazardous and handled accordingly.
Pathological and Tissue Waste
This includes all human tissues, organs and parts, placenta, embryos, remains of lab animals (guinea pigs), blood and biological liquids, to be disposed of. Under the same category, we find parts of human and animal bodies which are called anatomical wastes.
Pharmaceutical Waste
It includes all expired, vomited or stained medicines, pharmaceutical products, vaccines, plasma, bottles, cans, containers and ampoules of discarded pharmaceutical products. Other special type of the pharmaceutical waste is mutagenic materials which include anti- neoplastic medicines, which have pending harm and accordingly must be handled with great care.
Harmful Chemical Waste
They include all disposed solid, liquid or gaseous wastes of activities like laboratory tests, upon the area cleaning. Although there are relatively harmful and non-harmful chemicals; the waste chemicals, as far as human health is concerned, may be considered as generally harmful if having any of the following characteristics:
ƒ Poisonous chemicals albeit little or medium dose; ƒ Corrosive chemicals for materials and tissues (for acids of less than pH 2and liquids of more than 12 pH); ƒ Self inflammation and ignition; and ƒ Reactive (explosive or reacting with water) or collision sensitive.
The harmful chemicals frequently used in healthcare activities or maintenance of healthcare facilities and can be considered waste, are the following: ƒ Formaldehyde; ƒ X-Ray chemicals (for development and fixing purposes); ƒ Organic compounds (detergents, oils and insecticides); and ƒ Non organic compounds (non-organic acids, alkalines, chloride Ammonium solutions, oxidized materials and extracted materials)
Despite the variable definition and characteristics of the harmful chemical wastes, they are treated and disposed of in the same technique of the dangerous healthcare waste.
Radioactive Waste They include all solid, liquid and gaseous wastes which may be contaminated by radiation (or by radioactive nuclides of tissue or body liquid analyses (Whether in or outside the body by radiation examination or tumor prevention techniques and the different disease diagnosis and treatment mechanisms. It is noteworthy that these current guidelines must not consider in details the correct handling, treatment and disposal of radiation wastes which are regulated by Nuclear Energy Authority and Ministry of health in compliance with requirements and measures, provided for in the effective laws and legislations of Arab Republic of Yemen.
Pressurized Containers
Different types of gases are used in healthcare activities, whereby they are laid and stored in relevant pressurized containers like tubes, containers and cylinders as well as different types of aerosol. Naturally, these containers must be refilled, by the plant or the agent, after use, regardless of the possible remaining drops inside. It is essential to refer to the urgency in case of any damage of valves due to corrosion. Therefore, it is quite difficult to be certain of the degree of pressure the content of such containers is experiencing.
IV: Hazards of Healthcare Waste
This part includes a profile of hazardous healthcare waste handling, treatment and disposal related health and environmental hazards. For more information, please refer to relevant issues in ref 1. 2.
1- Personal Hazards All workers in healthcare facilities, patients and their visitors are exposed to infectious agent (micro pathogens) by handled wastes in these facilities.
It is worth mentioning that household (or household-like) wastes are not apparently hazardous to health or environment unless contaminated by infectious agent or hazardous healthcare waste. In such case, they must be classified as healthcare risk waste.
In case of long term storage of household waste, transport, treatment and final disposal workers may be subject to infection and/or poisoning hazards. The same applies to those responsible for sorting in landfill areas of household wastes.
Therefore, infectious, pathogenic and chemical wastes, in addition to sharp objects are considered as the most hazardous off all healthcare wastes.
Hazards of Exposure to Infectious and Pathogenic Wastes These wastes may include different types of micro pathogens, some of which may be active for long periods. Micro-pathogens may be infectious to human beings by one of the following ways: ƒ Punch or severe scratch of skin; ƒ Contact with mucous membranes; ƒ Skin wounds and cuts; ƒ Inhalation; and ƒ Swallowing Based on micro pathogens, their amount, and health condition of the exposed person(s), number of diseases or symptoms may be imminent.
There is special consideration for the possible infection by AIDS (HIV) and hepatitis B and C viruses in particular upon direct exposure to and contact with any virus stained healthcare waste.
Therefore, contaminated sharp objects (especially intravenous injection syringes), microbial culture media and other pathogens are highly dangerous and damaging to human health.
The following box presents vaccine requirements for workers as precautionary measures against infectious diseases upon exposure to infectious waste.
Workers Vaccine Requirements Apart from the prevailing vaccination program in the healthcare facilities, subject to their regulations, the following precautionary measures must be taken: - Protection of those working in transport and storage of HCW and specially
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infected ones, they must be vaccinated against HBV in 3 doses, with an interval of 8-10 weeks. No vaccine examinations before vaccination are taken. Vaccination can be taken at any time, with no contradiction with any other one. - For protection of workers exposed to TB, They must be vaccinated by BCG. Tubeculin test must be made before vaccination. If positive, no vaccination must be given .Generally those exposed, by virtue of their work, to TB, they must be tubercullin tested at intervals of 6-12 months. If changed from negative to positive, they must be treated by Isoniazide.
Box 1: Workers vaccination requirements
Hazards of Exposure to Needles and Sharp Objects Those may cause cut and punching wounds to the skin. Possibly wound infections, in case such needles and sharp objects are contaminated with micropathogens, could occur. Due to this dual danger (injury + infection), those sharp objects are the most hazardous and harmful HCW, so they must be handled with great care. Those objects must be collected in un-punchable hard bags as they are often stained with patient’s blood.
The following box provides the measures to be taken upon exposure to hazardous HCW or infectious needles and sharp objects.
Measures to be taken upon exposure to causes of infection by waste points: - Upon injury, washing any material of remains thereof in the wounds and surrounding skin with warm water and soap and disinfecting the area twice by alcohol or any prescribed disinfectants. - In case of any remains in the eye area, it is preferable to overflow the whole area with neutralized lotion. - Changing the contaminated clothes - Calling the emergency staff, if necessary - Asking medical assistance, after all above measures, for reducing the hazard of infection exposure. - Reporting the accident and sending a copy to the head department of the injured person and second one to infection control nurse or to occupational safety and health committee. - Taking immediate relevant measures for diagnosing any or more dangerous infections. - Testing any of the possible sources of infection by any of HB, AG, Anti HCV and HIV antibody and taking into consideration the quick tests - Reassessment of current situation for management of infectious needles and sharp objects wastes, personal behavior, use of personal protection means etc for non recurrence of such accidents Box 2: Measures to be taken in case of exposure to hazardous HCW or to infectious needles and sharp objects
Measures to be avoided: - Exposure to infection by good training, use of personal protection
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devices (gloves, nose and mouth masks) while serving the patient and changing gloves before serving the next one. - Exposure to sharp materials causing punched injuries either by avoiding their recover, bending or break or disposing of waste outside their special bins (thick bags for most waste or punching resistant safe cans for the needles). - Direct touch of any of the hazardous HCW. - Serving patients without good soap and water hand washing after and before any service Box 3: Measures to be avoided
Hazards of Exposure to Chemical Waste Many chemicals and pharmaceutical products are classified as hazardous to human health and environment, for having any or more of the following characteristics: - Poisoning - Inflammable or causing ignition - Deteriorating the genetic elements - Carcinogenic - Explosive - Corrosive - Collision resistant
The following box shows the measures of avoiding the exposure to chemical waste related health risks:
Measures to be taken: - Separation (sorting) of hazardous waste in the proper bins and bags. - Use of proper plates and bins, safe transport to ensure the reduction of spill and infiltration of harmful materials or punch by sharp materials. - Safe packing of hazardous HCW, as distinct of non harmful ones. - Wearing personal protection garments and equipment like gloves and masks especially on possible exposure to causes of infection, injury or spill of harmful materials. Measures to be avoided: - Direct touch of hazardous HCW. Box 4: Measure of avoiding the exposure to chemical waste related health risks
Hazard of the exposure to chemicals and pharmaceutical products depends upon their quality and quantity and the way of their entry to the body. Therefore, they must be recognized and handled with care.
2- Environmental Impacts There are a number of paths thru which HCW effects can reach the ambient environment of the healthcare facilities and its surrounding. Generally, these pathes could be included in:
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- Disposal of untreated HCW in mismanaged and uncontrolled landfills, where all harmful elements are available by virtue of winds, insects, rodent, rains, floods, waste discharge which may penetrate into the underground water through soil. - Emission of smug with its environmentally detrimental elements during uncontrolled incineration of wastes. - Disposal of harmful waste liquids through sewerage network which may have an access to lakes, rivers and other waterways.
These harmful elements by reaching the ambient environment, they get direct access human beings, animals and plants through potable water; surface or groundwater; and/or through the food chain.
V: Planning for the implementation of the HCWM system inside healthcare facilities
1- Preparation of Waste Management System
Almost all reviews carried out by different entities in healthcare facilities on the issues of healthcare waste indicated the existence of poor management and planning.
The relevant departments in charge of HCW in health facilities are exclusively responsible for the management of HCW. For developing and setting up such system, the following – but not limited to - steps must be taken:
- Collection of all relevant data of the current management procedure; - Review of all relevant current measures and responsibilities; - Acquisition of all safe handling of HCW related information (please refer to the instructions and measures of HCWM in this document); - Planning and budgeting of HCW management system; - Planning discussion with relevant authorities and departments (Infection Control Committee) and managers of healthcare facilities.
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A – Waste Treatment inside Healthcare B – Waste Treatment outside Healthcare Facilities Facilities
License Application to License Application to Ministry of Health Attachments: Ministry of Health Attachments: Full Fledged Contact with EIA other health Other Approval facilities/health Review EIA Study by requirements Document Review by facility. Environmental from relevant MOH Document Authority and authorities, i.e. describing safe reporting to MOH Ministry of waste transport Housing, process by the Ministry of applicant. Civil Approval Document Defense…etc Review/approval of MOH
License Approval License Approval
Fig.1: Profile of license application for waste treatment inside / outside health facilities
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The information and statements of HCWM development and execution may include the following elements: - Waste quantities divided by their different types and sources of generation, - System management organization and workers of sorting, collection, internal transport, treatment, external transport in addition to those responsible for system maintenance supervision and review (like committee of infection control), - Number of waste management staff, their educational background and duration of their activities, - Machines and equipment of waste collection, treatment and transport, - Waste handling adopted techniques.
2- Implementation of Waste Management System For such purpose, the following steps must be taken: - Development of an organization or internal department, with clear responsibilities, for regulating waste handling in the healthcare facilities. - Cooperation with other health facilities; - Development of basic internal capacities of the facility (machines, equipment and materials) for waste handling and management
a) Waste Management-Responsibilities There may be possibly a HCWM in some healthcare facilities but with no clear definition of responsibilities or means of inter-department cooperation. Some of the staff may have no access to the required efficiency except through the restructure of the existing departments with an additional financial allocation. One of the important waste management requirements in a health facility is workers training for HCW safe handling and performance according to the specified steps and concepts, (under the supervision of physician, one of the nursing staff or technician).This supervisor must be one of those responsible for applying techniques of infection control in the health facility.
In addition to the role of infection control committee, the health affairs department in rural and urban areas may cooperate in controlling HCWM system in the healthcare facilities. Those departments have the major role of monitoring progress of waste management in the different heath facilities.
b) Cooperation with Other healthcare Facilities Many healthcare facilities may have an interest in cooperation in the field of HCW treatment for lack of proper treatment techniques. What is more important is the vicinity of most health facilities which calls for more cooperation in cost effective collective hazardous waste treatment. Therefore one of the responsibilities of different health departments, with the cooperation of the urban and rural health departments is setting rules of cooperation and contact channels between different healthcare facilities for a final common system of waste management.
c) Internal Infrastructure For empowering the roles of HCW management for optimum performance, there is a need to develop relevant infrastructure in the health facility, to be supported with
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relevant equipment and supplies. There must be a clear mechanism of infrastructure maintenance for safe and cost effective handling This chapter presents some examples of the relevant machinery, equipment and supplies of such infrastructure in different healthcare facilities.
d) Training Training and information are indispensable elements for the development of HCM responsibilities. Health facility staff, especially those having definite responsibilities, must be given relevant trainings. Therefore all physicians, nursery staff, technicians and labors must be included in a specific and well developed HCW training program.
VI- Practices (Methods) of HCW Handling
1. Basics of HCW Handling: In principle, wastes must be stored in the nearest possible point of their generation. Getting into direct contact with HCW waste must be prohibited to everyone except those generating them. The basics can be summed up as follows: ⇒ Sorting waste: of specific and known types and their collection in separate manner, ⇒ Temporary storage: in intermediate locations prior to their transport either to treatment plant, if any, or to the main storage (collection) area in the healthcare facility or to special place, whether transported from different places or intermediate storage plants in the healthcare facilities, neighboring to a main plant, specified by the administrative authority. ⇒ Treatment of all hazardous waste by compact incineration process, except the following:- ƒ Expired medicines and pharmaceutical products-to be handed over again to the supplier. ƒ Pathological wastes (organs and body parts), to be handled as specified by the administrative authority. ƒ X-Ray development chemicals, to be disposed of to the contractors, specified by the administrative entity. ƒ Laboratory acids, which must be neutralized prior to disposal in sewerage networks ƒ Ensuring the sanitary landfilling of municipal wastes and its residual dust;
ƒ In case, incineration is not available, the following techniques must be undertaken: o Use of primitive mechanisms for hazardous HCW for limited periods and in exceptional cases, for example in remote areas pending the availability of appropriate environmental solutions for the replacement of such primitive techniques. Fig (2) shows two types of primitive machines of hazardous HCW.
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Fig (2) Two types of primitive machines of hazardous HCW
Fig (3): Small autoclave process
ƒ Safe landfilling: generally un-recommended, except for direct land filling in special cases and temporarily for land filling in remote areas where environmentally appropriate waste treatment techniques are not available. Direct land filling is an exclusive and indispensable solution for the final disposal of wastes in rural and poor growing areas. Therefore there is a need for operation and management of waste land filling in such areas. Following precautions must be taken prior to landfill ling of dangerous already or untreated HCW (frame 3);
- Direct land filling in limited special cases, for example the low generating waste of remote small - Healthcare facilities, lacking modern treatment techniques; - Laying untreated wastes in closed bags and plates, withstanding decomposition elements. - Disposal of HCW in special scared cells inside municipal waste land filling area;
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- Prohibition of direct touch of wastes by human beings or wild animals by : o Fencing the area and non spread of wastes in lager areas. o Total prohibition of sorting or capsizing contents of landfill. o Waste layer coverage by soil sand and dust. o Protection of wastes from torrents, floods, winds o Protection of surface and underground water of waste infiltration dangers by selection of far area. o The landfill of treated and/or untreated wastes, albeit, is the sanitary landfill, safe pit or waste landfill, must not be used for any other purpose. Box (5): Necessary precautions of land filling hazardous HCW.
Fig (4): Simple safe pit for land filling HCW
Waste transport outside the healthcare facility occurs in the following occasions: ƒ Transport of municipal (semi household) waste to the sanitary landfills; ƒ Transport of untreated hazardous waste to other healthcare facility having waste treatment plant. ƒ Transport of untreated hazardous waste for the sanitary land filling in case of absence of treatment capabilities. Wastes are transported to the final collection plant then to any of the following plants: - Waste treatment plants in other healthcare facilities or to a treatment plant outside the healthcare facility. - Waste final disposal sites which are designed to accommodate the hazardous and chemical waste. Residual incineration and solid municipal (semi household) wastes may be disposed of in an ordinary landfill.
As for healthcare facilities in remote areas or far from treatment plants and landfills, there must be a mechanism for their waste treatment. In all such events, relevant precautions and measures must be taken for the environmentally and occupationally proper treatment and sanitary land filling.
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For more information, please refer to UN Recommendations of Transport Dangerous Goods – UN Model Measures including recommendations of hazardous HCW transport (Ref 8).
Healthcare wastes are usually classified as hazardous. Therefore, relevant conditions and measures of their transport must be taken into consideration. Box (5) sums up measures of such dangerous waste transport outside the healthcare facilities. Box (6) presents some proposed bases of designing relevant vehicles and equipment for transport purposes. Fig (5), “Bio Danger” logo of hazardous healthcare waste, which must be fixed on plates, packets and bags of waste collection and their vehicles.
- Transport of HCW is forbidden except by licensed companies and authorities, taking into consideration the following precautions : - Capacity of waste containers is proportionate with their volumes and their maintenance is guaranteed. - Containers and vehicles must be free of holes or openings to avoid any waste infiltration. - Internal surfaces of vehicles are coated with galvanized steal, zinc or any specified material for cleaning purposes. - Waste transport contractor must notify the competent authorities with the vehicle garage address and ensure vehicle’s continuous cleanliness Box (6) Measures of high HCW transport outside the healthcare facilities.
- Design of transport vehicle chassis must be compatible with volume and amounts of wastes to be transported , to give more accessibility for the relevant workers - Provision of a distance between the vehicle’s driver and the container for any emergency accident. - Provision of a system for anchoring and stabilizing waste containers for avoidance of waste spill/infiltration or scattering. - Provision relevant equipment of spill and waste collection inside the vehicle. - Vehicle’s internal finishing must be appropriate for its cleaning, in terms of its round angels. - “International Logo of Bio Danger” must be fixed on the outside walls of the vehicle and transport containers. Box (7) Design provisions of hazardous healthcare waste transport.
Fig (5) International Sign of Bio Hazard
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2. Internal Handling of HCW Inside Healthcare facilities HCW disposal must be undertaken under the following principle: “Placement of all HCW in red bags or specified relevant containers; General (municipal) waste must be placed in black and radiated wastes must be placed in National (or International) Nuclear Power Organization recommended containers.
Fig (6) shows the hierarchy of HCW in the context of an integrated waste management.
Sorting waste in points of generation
Waste collection &transport inside health
Temporary storage of waste
Waste treatment in /outside health care facility
Waste transport outside health care facility
Waste final disposal (usually in a landfill)
Fig. (6) Hierarchy of HCW in the context of an integrated waste management system
Infectious Needles and Household/ Household-like waste Sharp Objects Chemicals Wastes
Box of Chemicals Red Bag needles Containers Black Bag
Final Disposal in Sanitary Treatment Landfill
Fig (7): Principles of sorting different types of waste inside healthcare facility
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Dual system for waste collection: - plastic Dual system of waste collection in baskets include plastic bags, the red for intermediate storage room: two metallic hazardous waste and the black for household cracks for plastic bags, one red bag for and semi household waste. hazardous waste – the other, black bag, for municipal (household-like) waste.
Safety boxes for collection of needles and sharp object Fig (8): Illustration of different types of containers, plates, bags and cases to be used in sorting and collection of different healthcare types of waste
Usually sorting and collection of hazardous healthcare waste are laid on the patient service (Nursing) trolley (fig 9) for proximity to doctors and nurses
Fig (9) Patient service (Nursing) trolley: - on shelves are sorting and collection materials of hazardous healthcare waste
Table (7) shows the main characteristics of applying tools of HCWM system inside a health facility, most particularly regarding the tools of waste temporary sorting, collection and storage.
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Table (7): The main characteristics of applying tools of HCWM system
Application of Tools Characteristics Nursing Trolley - stainless steel, with highly durable wheels - provided with three shelves - Provided with lateral side rack including stainless circular plates-5 mg with 5cm distance. - The rack is hook mounted on either side of the vehicle. This rack dimensions are 30x15x40cm (length, width and height respectively) Rack for storage room - Stainless steel. - Circular /round surface on ground level - Sides are made of two metal plates- 77cm high. - Diameter of higher surface ring is 50 cm. - Rack base is fixed on 6 rubber bases Small covered basket - Made of lead & cadmium free Polypropylene material. - The cover is of the same material.. - Height: 50 cm - Diameter 35 cm 360 L container for temporary storage and - Made of plastic /fiber glass waste transport - Cover of same material. - Provided with two wheels and knob. Small needle case - Made of cadmium free acid resistant Polypropylene, - Capacity 1.5 - Cylindrical shape - Covered with a cover Plastic buckets (for chemicals and broken - Made of Polypropylene, cadmium glass and porcelains free, acid resistant. - Capacity : 10 L - Cylindrical shape - Tightly closed - Provided with plastic/metallic, centrally fixed handle Small red bags - Made of Propylene-cadmium free. - Red and opaque - Thickness 60 micron - Height : 35 cm Large red bag - Made of Propylene-cadmium free - Red & opaque
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- Thickness: 80 micron. - Height: 110 cm
3- Code of practice for waste types handling Following is a description of a code of practice for waste type handling, with regard to the following elements: ƒ Separation in point of origin; ƒ Packing techniques. ƒ Fixing labels; ƒ Intermediate storage; ƒ Collection; ƒ Waste internal transport; ƒ Transport waste from the health facility to the main plant.
There must be a specific code of practice for any facility in need of specific techniques or materials of waste handling. Facilities like blood banks, laboratories and delivery facilities are all included in this context.
Hazardous healthcare Waste handling inside the Facility Separation of hazardous HCW ƒ Hazardous waste must be sorted (separated) in the nearest point of their generation /production; near the patient service areas and in all cases, near the dressing trolley ƒ Hazardous HCW (like blood bags) must be laid in red bags tightly fixed, after which, they are laid in another red bag (either in the small bag which is fixed in the dressing trolley or in the bigger bag; on the bags rack in the intermediate storage chamber). ƒ Hazardous liquid healthcare wastes (including harmful chemical wastes) must be disposed of in liquid infiltration free packets/containers/buckets (5-10 L) on dressing vehicle/ intermediate storage chamber ; ƒ Needles and sharp objects must be disposed of in the relevant packets over the dressing trolley or over the patient treatment table; ƒ Nursing staff chief of each facility must advise the store man for the provision, whenever necessary or on stock deficit, of red (small and large bags) and packets, containers and needle point disposal cases.
Storage of Hazardous HCW ƒRed bags, filled with hazardous waste till its two thirds, must be tightly closed and laid in the bigger red bag mounted on the rack in intermediate storage room in the facility. ƒNeedles and sharp objects boxes and containers must be tightly sealed by their lids, and then laid inside the large red bag fixed on the rack in the intermediate storage chamber. Packets and containers (5-10 L) filled with hazardous waste must be tightly sealed and laid on the storage room floor. ƒUpon the fullness of the large red bag on the rack; till almost its Three- quarters, it must be removed and tightly closed by the sealing machine fixed on the intermediate storage chamber wall. Then the closed bag must be laid on the room ground and with a label indicating its content and the facility name.
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Another clean big empty red bag must be mounted on the rack to replace the previous one. ƒFacility name must be fixed on all full bags, packets and containers of HCW laid on the floor of intermediate storage chamber. ƒOn daily basis, intermediate storage chamber must be cleaned by cleansing trained workers.
Fig (10) shows some types of intermediate storage rooms in the health facilities.
Fig (10): Some types of intermediate storage rooms in the health facilities
Hazardous healthcare Waste Collection and Transport from a number of nearby healthcare Facilities (or a Compound of healthcare facilities):
ƒHazardous healthcare waste in big red tight-sealed and labeled bags, specific packets and containers, laid on the ground of the intermediate storage chamber, must be collected by collection workers, at least once daily. ƒWaste bags, packets and containers must be collected by workers in specific trolleys along the way from the healthcare facilities to the main collection plant (One of the plant Manager’s responsibilities). ƒUpon waste arrival to subsidiary collection plant, the trolley must be discharged into wheeled yellow containers. ƒWheeled containers must be collected once/day at least by trained workers and transported to the main collection plant. ƒFilled wheeled containers must be replaced by new empty, clean and ready to use ones. Nursing chief in each department must issue orders for the supply of red (small and big) bags as well as other packets and containers for waste sorting (separation), whenever necessary.
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Main Collection Plant ƒHazardous healthcare waste, which are collected from the neighboring healthcare facilities compound by the wheeled trolleys till the main collection plant must be immediately emptied in wheeled containers. ƒWheeled containers must reach a specified inlet area then to the waiting/temporary storage/refrigerated place – (pending the arrival to the place of incineration /disinfecting /….) or directly to the treatment machine ƒUpon emptying the wheeled container's contents in the treatment machine, the containers must be evacuated for cleaning and storage in specified area. ƒWhenever treatment machine is not operating, the filled wheeled containers must be removed to the refrigerated storage area.
Treatment of Hazardous Healthcare Waste ƒDuring duty hours: Incinerators must be filled continuously with hazardous healthcare wastes. ƒResidual ash must be removed before the treatment of the next wastes. ƒResidual ash must be collected and laid in special containers prior to transport and disposal outside the treatment unit ; ƒResidual ash containers must be covered before its transport, with due care of non dust scattering by sprinkling little amount of water. ƒThe residual ash containers must be transport, daily if possible, to the sanitary landfill.
Pharmaceutical Wastes It includes medicines which contents were used and recovered from patient rooms and it should be handled as harmful wastes. Closed and/or unused medicine packets must be reenlisted in the pharmacy. In all cases, medicine packets or residuals must be delivered to the producer /supplier. In case there is an incineration mechanism qualified for chemicals treatment as well, this can be incinerated. If otherwise, the pharmaceutical wastes must be landfilled in safe pit.
Harmful Chemical Wastes It is handled in the same way of the hazardous healthcare waste. Most of the clinically chemical wastes must be recognized, so as to apply the specific codes of practice, for, various types of chemicals cannot be mixed, accordingly must be maintained separately, unless otherwise prescribed in the clinical assistance codes of practice.
General (Municipal/Household-like) Solid Waste In all cases, all these wastes must be handled separately
Handling of General Solid Waste in Healthcare Facilities
Separation: ƒThese types of waste must be sorted at the nearest point of their generation (production) and of patient treatment place, in outpatient clinics, laboratories, blood banks and health offices (during vaccination for example). ƒThey must be collected in their specified baskets; lined with black bags,
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except the paper (cardboard) boxes ƒPaper and cardboard boxes must be collected separately and bound in the least vacant area. Storage: ƒSmall black bags must be collected, at least once /day or upon their fullness and must be tightly closed and disposed of in the big black bag, hung in the rack of the intermediate storage chamber; ƒUpon its fullness with the small black bags to its three forth of contents,, the big black bag must be removed from the rack and tightly closed by the machine, fixed on the wall of the intermediate storage chamber, and then laid on the ground after which a big black bag must be fixed on the rack. ƒAll paper boxes and containers must be bound and lined to be in the least possible area and laid on the floor of the intermediate storage chamber; ƒNursing official in each health facility must provide the black small and big bags and other containers for collection of wastes, from the subsidiary warehouse ; ƒCleaning labors are responsible for the daily cleaning of the intermediate storage chamber and the weekly maintenance and cleaning of garbage collection baskets.
General (Municipal/Semi household) Solid Waste Bag Collection and Transport:
ƒFrom Neighboring Compound of healthcare Facilities
ƒClosed bags and packets , bound paper ( cardboard) boxes – all laid on the floor of the intermediate storage chamber – must be collected and transported , once a day by workers. ƒAll bags and packets …etc must be collected by workers and loaded on the waste transport vehicle, along the way of the compound of the neighboring health facilities through the main collection plant. The main plant manager must be responsible for waste collection workers monitory and control. ƒFor facilities, having no vicinity with other health facilities, separate path, through the main road, must be outlined for their waste collection, which must be done by the truck driver till the main plant. ƒDirectly, upon the receipt of bags and packets in the main plant, they are transported to the specified containers outside the plant; ƒAll filled containers must be collected once daily. New ones must be laid; ƒIf filled before the coming of the waste transport vehicle, the main station manager must be reported to send, urgently additional ones.
Main Collection Plant
All General (Municipal /Semi Household solid waste which are collected by the vehicle must be evacuated –upon arrival to the main collection plant inside specified containers.
o Disposal of General (Municipal/Semi household ) Solid Waste:
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ƒContainers must be evacuated at least once daily and be replaced by empty and clean ones. ƒMain waste collection plant manager is responsible for waste handling processes change and control.
VII: Emergency Measures
All healthcare facilities, participating in the HCWM system must make a separate plan for handling emergency cases. This part must detail the main measures of handling such emergency cases in HCWM.
1- Individuals Injuries 1- These occur because of wounds and tissue contact with pointed materials and by inhalation. 2- First Aid kit must be provided in each health facility for immediate service for wounded people. 3- In case of a surface wound, simple first aid is enough; 4- In case of sever injuries, the physician examination is recommended; 5- In severe cases , the wounded must be carried to the Emergency Department for treatment, 6- In all cases, infection control, safety department, occupational health and health insurance official must be communicated of the accidents and injuries.
2- Spill/Scatter of Liquids during transport of hazardous HCW: 1- In case of spill/scatter of hazardous HCW solid materials inside the facility, those must be immediately collected by a shovel inside a new red bag. 2- If such spill/scatter is outside the buildings and the internal roads of the facility, those must be immediately collected by a shovel inside a specified case or container albeit those were inside red or black bag; 3- In case of a spill inside the facility, the waste collection man must report to the main waste collection plant manager. 4- In case of a spill outside the buildings and facility internal roads, some dust and earth must be thrown on the spill point and then collected by shovel inside a specified container or plate and reporting the plant manager of the spill.
3- Cut/Damage of Waste Collection Packet in Departments/Intermediate Storage Rooms 1- Incase of a cut /damage of waste collection packets ( bags or packets/containers) inside a facility , those must be immediately collected in another bag /packet of the same cut or damaged type ; 2- In case of the scatter of needles and sharp objects, absolute care must be taken upon their refilling by use of thick gloves or shovel for picking up the scattered materials and putting them in a container ; 3- In case of a cut /damage of big bags in intermediate storage room, the bag must be reloaded in new and safe bag; 4- In case of a cut /damage in any of different liquids packets in the intermediate storage room, they must be refilled with their specified liquids. Point of such spill must be cleaned ; 5- In case the above is in the department, nursery chief must be reported. If in the intermediate storage chamber, nursery chief and the waste
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collection main plant manager must be reported;
4- Fire Fighting Arrangements 1- Site Description : ( Area- Limits) 2- Site Elements Description: building area- building type- Service Wards- stores- utilities which include number of doors and different types of storage of each element. 3- Security Plan : including sources of fire water network (Number of fire tanks and taps- capacity of fire tanks, mechanism of fire network operation- options in case of power failure), manual extinguishing equipment) number- content type: powder or CO2 or sand or halon – content weight ).
VIII: Monitoring Plan
HCW system documentation plan must be affected upon the completion of applying the system in other health facilities. But there is no reference here to Ministry of Health and EEAA recommended environmental documentation measures and workers examination which is controlled by infection fighting committee.
1- Documentation of possibly hazardous HCW :
1- Upon collection of hazardous HCW from intermediate storage chamber, number and name of the producing facility, of big red bags and other packets in special form with the waste truck driver. 2- Total number of containers ,which contents are unloaded in treatment area ,must be recorded in special form in the main plant of waste treatment; 3- All documents of red bags and packets, unloaded in treatment area, must be computerized in the main collection and incineration plant.
2- Documentation of General (Municipal/house hold-like) Solid Waste: 1- Upon the collection of General (Municipal/ house hold-like) Solid Waste from intermediate storage chamber ,each black bag must be documented by inserting number and name of its facility in special form with the truck driver ; 2- Main waste collection plant must be provided with a scale form weighing the hazardous, general solid HCW.
IX: Traditional Problems and Possible Solutions of Waste Handling
Table (8): Types of Traditional Problems and Possible Solutions of hazardous HCW Management System
Traditional Problems Possible solutions according to local conditions 1- Intravenous injection punching - Intravenous sets must be inserted in plastic waste collection bags and causing buckets instead of plastic bags and covered injuries upon being filled.
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- On using Glucose /salt contained plastic packets, such contents must be separated from the needle; the former must be disposed of in bags and the latter in their packets. On use of glass bottles, those with intravenous set must be disposed of in the plastic bucket to avoid glass break and injuries. - Uncovering syringe needles or intravenous set for the non return of their contents ,causing infection 2- Use much of glass solution - Ensuring the absence , in such contents, of packets and taking high cost of causes of infection by avoiding return of their disposal into consideration intravenous set contents to the bottle by use of special packets ,otherwise they must be deemed non infectious thus can be handled separately and collected in cardboards packets, sold …etc. 3- Many full blood bags - Use of covered buckets instead of traditional bags; - Use of bags for collection of 1-4 ones and closing them tightly before inserting in big thick red bags or inserting blood bags inside many bags to ensure no infiltration and use of more bags, whenever necessary. 4- Difficulty of avoiding the - Bringing their packets on the nursing recover of needles vehicle inside patients on receiving treatment to avoid the recover of needles and disposing of them in the nearest red bag and needles in the collection bag 5- Blooded dressings - Laying them in small red bags and tight closure before inserting small bags in the big thick red bag 6- Dialysis equipment sharp parts, - The sharp part may be separated and laid perforating bags, thus increase in the white bucket of hazardous waste infection dangers 7- Bad separation/sorting of - Closure of contaminated bag and inserting wastes and infectious wastes it in big red bag. No infectious waste must be inside the municipal waste hand sorted /handled collection bags 8- Disposal /handling of needles, - Buying (use) of their boxes (50cm high) in and sharp objects departments using them, otherwise, those to be disposed of must be laid in other buckets. - Non use of force, bending or breaking the sharp materials to avoid more injuries 9- Handling wastes without - In case of collection of infectious wastes separation/sorting inside ordinary waste collection bags , the full bag must be laid in the red bag , and all wastes are treated hazardous - If sharp materials are inserted in a waste collection bag ,this should be handled with great care (in bucket or plastic plate ,pending
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their treatment) plate or bucket can be washed again 10- Handling blooded bags or - Strong plastic covered buckets /plates, placenta otherwise bags/placenta must be inserted in thick red bags (more than 60 microns), to be tightly closed and laid once more in big red bags and closed again. Big red bags must be inserted in strong plastic plates prior to transport to treatment plant
By reviewing the standard possible solutions of the HCWM system undertaken, we may take for granted that these solutions are meant as guidelines. More solutions may be proposed based on the availability of machines and equipment, workers’ personal experience and skills, the material resources, maintenance tools and the environmentally safe working atmosphere including means of control over possibly contagious resources.
It is recommended that the disinfection control committee for proposal and execution of solutions is consulted for solutions to problems hampering the HCWM system including specifically hazardous waste from the diagnosis and treatment departments in the health facility. It is important to know that applying the standard solutions to HCWM system problems calls for the purchase of more equipment and supplies to ensure good process of work and its detailed control and alignment.
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Chapter 2: Management System
I: Executive Unit and its Organization Chart
The main task of the executive unit is the management of "collection, transport, treatment and safe disposal of all HCW generated in healthcare facilities. The unit’s responsibilities are detailed as follows:
1- Periodical waste collection from health units, clinics and laboratories, upon agreement of the unit and each health facility. 2- Waste transport to the treatment plant; operated and maintained by the unit through already decided paths. 3- Incineration dust transport to the safe land filling area. 4- Purchase of the in-origin healthcare waste separation (plastic bags, cases/containers of sharp materials), storage and distribution to the healthcare facilities. 5- Undertaking the administrative and financial measures of unit operation, including reimbursement of the unit usufruct service fees from the health unit by an agreed upon system.
Organization Chart of the Executive Unit In the current organization chart, the executive unit is affiliated to the competent health department (Fig11). There is close interrelation between the health unit and department, as provided for in the nomination, by the department, of the unit manager. The chief financial manager of the health department is the supervisor of the unit financial affairs, through controlling the permanent financial official of the unit.
Organization Chart of the executive unit includes the unit manager, operation controller, financial affairs chief, and unit secretary (in charge of complaint affairs). The operation controller directs, monitors and controls (1) machine and equipment operation and maintenance controller (and of incineration operators, garage and maintenance workers supervisor). (2) Administrative officer (in charge of drivers, loading workers and store man). The financial officer directs and monitors account clerk and store chief).
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Head of Health Dept. Manager Financial Affairs
HCWM Unit Manager (Permanent)
Unit Secretary- Complaint Manager (P)
Operation& Maintenance officer (P) Senior Financial Affairs (P)
Administrative Operation & maintenance Chief treasury (P) Account clerk officer (P) supervisor (P)
Waste transport Garage Incineration driver (P) Maintenance (P) operator (P)
Store chief Security men (P) Rising ash Maintenance Waste handling and chemicals workers (P) workers (P) Rising Gases
Fig (11) organization chart of the executive unit
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II: Monitoring & Evaluation Unit Staff Performance
This is done in the framework of an integrated system of performance management. The propose program of performance management is briefed as follows:
1- Design and documentation of the systems and work procedures of the unit’s main activities. Performance indicators are conceptualized from the role of all workers in the documented work systems and procedures and their job description. 2- Performance indicators must be linked with three scales : • Realization of the main goals of the job (Job Purpose) • Maintaining the used materials in good condition. • Rational use of available materials and resources; 3- Arranging meetings between the competent officer and his senior official for understanding and clear definition of performance indicators and mechanism of their empowerment 4- Measurement of realized actual performance must be made in comparison with performance indicators. 5- Differences between actual performance and performance indicators must be handled, first by corrective measures, concluded by the competent officer with his senior official, and with full support in a bid to realize the appropriate corrective measure. 6- Any successful officer, in terms of the corrective measure, must be appreciated. 7- Any rebuke of penal measure must be inclusive only in case of flagrant negligence or unjustifiable mistake.
An example of the way of starting the realization of performance management plan, as referenced above, the present code of practice, refers - as follows - Proposed performance indicators for drivers and collection labors.
They are extracted from vehicle operation instructions and job description. Accordingly the proposed performance indicators must be as follows:
1- Number of driver’s and his labor’s monthly failure for delivering healthcare waste loading materials to the healthcare facility and taking into consideration the volume of the output wastes of the competent health facility. 2- Number of monthly bad fixing of healthcare wastes and their spill in the vehicle. 3- Number of annual non compliance with sound operation measures and the entailing spill outside the vehicle (with due consideration to the serious dangers of such spill in terms of nature of spilled material and place of such spill). 4- Monthly and quarterly reviews of the compliance with the vehicle's preventive maintenance plan. 5- Routine reviews and sudden inspection of the driver's compliance with his already decided path. 6- Quarterly review of the vehicle's condition
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References 1- Safe Management of Wastes from Health-Care Activities, WHO 1999 (in English only) 2- Guidelines for Health Care Waste Management and Infection Control, Ministry of Health and Population, Egypt, 1999 (in Arabic only) 3- Audit Evaluation Report, MOHP/EEAA/DANIDA Health Care Waste Management Project, 1999 (in English only) 4- Evaluation of Institutional Settings for Health Care Waste Management, MOHP/EEAA/DANIDA Health Care Waste Management Project, 2000 (in English only) 5- Description of Applicable Health Care Waste Treatment Technologies, MOHP/EEAA/DANIDA Health Care Waste Management Project, 2000 (in English only) 6- Regional Infrastructure Classification of Health Care Waste Management, MOHP/EEAA/DANIDA Health Care Waste Management Project, 2000 (in English only) 7- Evaluation of Legislation Related to Health Care Waste Management, MOHP/EEAA/DANIDA Health Care Waste Management Project, 2000 (in both Arabic and English) 8- Recommendation on the transport of dangerous goods - model regulation, 10th revised ed. New York, UN (ST/SG/AC.10/1/Rev.10).
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Annex 3: Documentation Package of the Public Consultation
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Annex 3-A Sample of the Public Consultation Workshop Invitation
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Annex 3- B: List of Participants of the Public Consultation Workshop- Health and Population Project -Sunday 06/06/2010
Ser Name Position Telephone Email
Reproductive Health Aysha Mahdy Amer Al 1 Supervisor – Bani Matar - 777467276 Sadihi Sana'a Kuboul Sharf Eldin Community Health worker- 2 770991054 Ahmed Khawlan
Takeyah Mahmoud Al Community Health worker- 3 714940974 Luheim Bani Matar
Community midwife- 4 Abeer El Nahary 777367431 Arhab
Dr. Omar Ali Abd El Deputy Health Director – 5 77745693 Wahab Ad-dalea
Dr. Khaled Abdo El Director of the Health 6 777901572 Montasr Office – Sana'a
Dr. Fouad Hussien Al Director of the Health [email protected] 7 777392375 Hawri Office – Hamadan
Abd Allah Ahmed Director of the Health 8 777477180 Hassan El Modaehi Office – Manakha Dr. Abd Elsalam Executive Director of the 9 Mohamed Hamid Al Mother and Neonatal 777238853 Oreifi Health Program – Sana'a Ahmed Hussein Head of the Health Office - 10 777743181 Mohamed El Amery Al Bayda
Amal Mohsen Aly Abou Reproductive Health 11 329543 Salah department – Bani Hashish
Om Hany Abd Allah El 12 Health Office - Sana'a 7770 61494 Mahdy
Mona Mahmoud. El 13 Community midwife- 771373788 Shawshy
Pharm. Aly Muthanna 14 Health Office - Raymah 777441146 Aly
Abd Allah Abd El Wahab Family Health Care NGO- 15 770382493 Naser Ibb
Ahmed Mahmoud Aly Al Head of Al Amoush Health 16 777462398 Odeiny Center – Mutheikhra - Ibb
Mohamed Hassan 17 Health Office - Ibb 771861850 Kassem
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Ser Name Position Telephone Email
18 Fouad El Shaweshy Health Office – Sana'a 777186156
Member of the Executive 19 Dr. Ahmed El Nouamany Body of the Council of 733883742 Ministers of Health
20 Nagy Aly El Nahamy Head of EPA Office – Ibb 777606433
Mohamed Ahmed El Director of the Health 21 777328156 Seragy office – Sayaan
Dr. Ghaleb Abdo 22 Health Office – Raymah 777620983 Mohamed Taher
Dr. Gamal Mansour El Member of the Health 23 711833129 Sayedi Policies Unit
[email protected] 24 Dr. Dhekra A Annuzaili World Bank g
Dr. Qaed Mohammad Health Policies Unit 25 777795594 [email protected] Obadi Advisor
Dr. Ahmed Mohamed Health Policies Unit 26 777416149 [email protected] Aklan Advisor
Dr. Mohamed Abdel Director of the Health 27 777291199 Mawla Al Samawi office – Al Bayda
Dr. Abdel Gabar Aly Al Information and Research 28 733800462 [email protected] Ghaithi department MoPHP
Mohamed Abd Allah El Head of the Reproductive 29 Hashash Health – Ibb
Eng. Helal Aly saleh El Environmental Protection 30 733835643 [email protected] Raiashe Agency (EPA)
Director of the Health 31 Dr. Mohamed Saad Taher 771770499 [email protected] office – Raymah
Eng .Abdel Kudous 32 Project Coordinator 711594645 [email protected] Mohamed Al Sharafi
Malaria Program Expert - 33 Dr. Kamal Moustafa 734453737 [email protected] WHO
Dr. Mohamed Yahia El Head of the Doctors 34 777339910 Shamy Syndicate – Sana'a
Representative from EPA – 35 Gamal Abdo Sofan 777300367 [email protected] Sana'a
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Ser Name Position Telephone Email
Ms. Samira Mohame Head NGO (no name 36 777749839 Hatem indicated) – Sana'a
Ms. Radiya Abdallah El Director of Women 37 Hady Department – Sana'a
Head of the Reproductive 38 Dr. Nadia Saad Kaid 777001034 Department – Aden
Mother and Neonatal [email protected] 39 Dr. Lina Yasin Amin 733566192 Health Program m
40 Aly Al Solihe Health Policies Unit 777282670 [email protected]
General Director of Salem Abd Allah 41 Environmental Monitoring 777329607 [email protected] Baquheizel (EPA) – Sana'a Ibrahim Mohamed Head of Environmental 42 700111334 Ahmed El Hazen Protection office – Sana'a
Minister of Health Advisor 300771 43 Osman Mohamed Osman for Legal Affairs 771772922
Planning Undersecretary's 44 Dr. Ahmed Al Ukabi 713448476 [email protected] Office Director
Yamaan Association for Dr. Abd El WahabEl Al Health and Social Abdulwahab.alansi@yam 45 711799518 Ansi Development (Social aan.org Marketing Project)
46 Dr. Aly Mohsen Melosy Child Health - MoPHP 777566300
Dr. Naguib Khalil Abd El 47 Child Health - MoPHP 733641455 Gawad Head of the health Sector- 777382097/ [email protected] 48 Dr. Said Kamel Charitable Society for 713093031 Social Welfare (CSSW)
49 Abdel Khalek El Bahry Al Thawra Newspaper 777112976 [email protected]
Family Health Care [email protected] 50 Dr. Sumaia Alariki 733721441 Association (NGO) m
Head of the Reproductive [email protected] 51 Dr. Eman El Kobaty Heath, MoPHP m
Vaccination Department, 52 Taha El Akaby 777201969 MoPHP
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Ser Name Position Telephone Email
Director General of Private Dr. Abd El Rahman El 53 Health Facilites Hamady
Dr. Nabiha Abd El 54 Curative Care Sector Rahman El Abhar Head of the Health Ms. Fayza Ahmed El 55 Education Department - 777183230 Salan Ashhbaa NGO, Manakha
Dr. Mujahid Hassan El Head of the Health Office 56 777901220 Maazal – Bani Matar
– Undersecretary of the 57 Dr. Mohamed Bajunaid MoPHP General Director of the 58 Dr. Ali Mudhwahi Family Health dept. MoPHP Dr. Muhamed Muthana Environmental Department 59 Salem MoPHP ESIA Coordinator and [email protected] 60 Mrs. Amal Faltas Social Development Expert – EcoConServ Environmental Expert – [email protected] 61 Eng Ahmed El Sabban m EcoConServ
Social Development Expert 62 Nadia Shaher – Jet Yemen
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Annex 3-C: Scanned Registration Form of Participants of the Public Consultation Workshop
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Annex 3- D: Sample of the Participants’ Written Feedback Sheets
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Annex 3- E: Summary of most of the received environmental comments
Speaker Comments 1. Miss Fayza Al Hayrat – Al • Increase the focus on the generated Healthcare waste and Shahbaa methods of its safe disposal and consider it as an Association important issue. (NGO) • Thanks for the efforts expressed for the study and for the presentation. 2. Mr. Nagui Ali Al • Focus on the application of Mitigation measures Nahmy – Genral • Training courses, forums and workshops for handlers of director of HCW Environmental • increase of awareness programs for the population (use Bureau – Sana'a social leaders and media) (Gov.) • Financial allocations for the application of the above. • Providing appropriate alternatives to the existing dumpsites. 3. Dr. Adbel • The problems presented (mainly HCW) is deeper in Rahman Al dimension. It represents a National Problem. This needs Hammadi – more workshops to elaborate an applicable compelling ministry of National Strategy and/or Policy. Health 4. Dr.Omar Ablde • There are many methods for safe disposal of HCW. The Wahab – Al safest is the correct landfilling. Dalea • It is good that the study has taken into its consideration 5. Mr. Jamal the environmental aspects. Sawfan – Sanaa • Governorate This applies to HCW, which consists of a danger on the human health. 6. Eng Abdel Kudous Al • The study was very useful, good and comprehensive. Sharafi – MOPHP • Healthcare workers must correctly dispose sharp tools and HCW in its incineration boxes. 7. No Name • There are no fixed personnel in Health facilities in charge for cleansing. • No fixed budget allocations for cleansing. • Good event. • Good presentation f the environmental current status. It 8. Dr. Mohamed Al reflected exactly the current situation as it actually is. Samawy – • Budget allocations for cleansing are very low. MOPHP Al • Bayda There is a must for the creation of an Environmental Department inside the MOPHP. • This department must be operational.
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Speaker Comments • Each Governorate has its own special conditions. Therefore, mitigation measures must be case-sensitive 9. Eng. Hilal Al and consider the differences in conditions between Riyashi – General geographic areas of the project. Authority for • Financial arrangements for HCW management must be Environmental included within the Environmental Management plan. protection • Budget allocation of the project for safe disposal of liquid, solid and gas wastes 10. Mis. Abir Al • The study is excellent and of a great importance. Nahary – Arhab • The most important thing is the application of a strict Hospital system of management and safe disposal of HCW. 11. Mr. Salem • HCW: no open air incineration is accepted. Baquhaizal – • These should be sterilized and or incinerated in special General incinerators. Authority for • There is a National Strategy for Safe disposal of HCW. Environment • Protection Budget allocation for safe disposal of HCW. 12. Mis. Amal Abu • Excellent Study. Salha – Beni • We wish the conditions of Healthcare workers are Hashish improve in order to protect them from actual dangers. • The ESIA project is very good and the HPP is very important. 13. Dr. nadia Kaed – • Attention must be given to the HCW issues and Health office of management and safe handling and disposal. Adan • the same goes for storage and safe handling of chemicals and drugs. • In case incineration of HCW is applied a trained and competent personnel must be assigned for managing of 14. Dr. Ali Mohsin – incinerator and safe disposal of wastes. MOPHP • Coordination with other relevant authorities is a must in the issues of HCW management. • Interesting presentation and Comprehensive study. 15. Dr. Gamal Al • Suggest including the field visit findings in a table. Saiedy MOPHP • Classifying the HCW into categories and presenting methods of safe disposal separately. • Correct study as regards environmental aspects. 16. Kaboul Ahmed – • Jihana Khawlan Recommendation of the study must be taken into consideration in order to keep a sane environment • Basic environmental problem is the ill level and working 17. Mis. Aisha Al conditions of Healthcare workers psychologically and Suraihi – Sanaa economically. • The study is excellent and correct from environmental 18. Mis. Thania Al and social impacts point of view. Luheim – 26th of • The presented actual status of HCW management and Sept. Hosp. in handling is correct and real. Bani Matar • Incineration could be fine but it is not done all the time. • Financial allocations in this regard are not sufficient and
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Speaker Comments this is the key factor. • Healthcare worker needs more awareness. • The status of cleansing efforts in healthcare facilities is 19. Mr. Ahmed El very low. This is due to the low availability of financial Amadi Albayda support. • The plastic and polyethylene waste bags have not been 20. No Name covered by the study. These represent a great danger on agriculture.
Annex 3- F: Public Consultation Article as Presented in Al Thawra Newspaper, 7th June 2010
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