World Bank Document

FINAL

Republic Of Uganda MINISTRY OF HEALTH Public Disclosure Authorized ENVIRONMENTAL AND SOCIAL IMPACT ASSESSMENT FOR PROPOSED RENOVATION AND EQUIPPING OF HEALTH FACILITIES IN UGANDA

(Proj Ref: MoH/SEVCS/HI/08-09/00732)

Volume 4 of 4: Western Region facilities Public Disclosure Authorized Isingiro Ntungamo Mbarara Public Disclosure Authorized MINISTRY OF HEALTH AWE Environmental Engineers Environmental, Civil Engineers & Project Management Consultants Public Disclosure Authorized

April 2010

Consultants:

Name and Qualifications Role Signature

Lead Consultants: Eng. Lammeck KAJUBI; PE., CEnvP Herbert Mpagi KALIBBALA, CEnvP Mrs. Pamela Tashobya, CEnvP Contributing personnel: Oyen Ben David: Faith Mugerwa: Eng.Dr. John Baptist Kirabira

Ritah Naba ggala Emmanuel Bazibu

Subsidiary: Pollution Control Equipment LLC, representing: Document control:

Doc.No: TU/EW7-10 Markleen (Norway): Oil spill control equipment / technologies QA by: TP, EN Industrial Scientific-Oldham (USA): Gas detection & monitoring equipment Appr by: LK Advanced Disposal Technologies, ADT LLC (USA): Hazardous waste treatment, Site remediation technologies Issue date: Mar 2010 Enviro Technology Services PLC (UK): Air Quality Monitoring Equipment & remote systems EEC Global Operation, LLC (USA): Package wastewater plants

Acronyms and definitions

iii

Units and measures

Definitions:

Dioxins Incineration: Infectious Waste:

Hazardous waste Hospital Waste:

Medical Waste: Solid (non-hazardous) wastes:

Point sources:

Contents

vii

Tables

viii

Executive Summary Uganda Health Systems Strengthening Project Health Infrastructure 01 THIS PROJECT: EXISTING CONDITIONS AND PROPOSED RENOVATIONS a) Regional Referral Hospital b) General Hospitals Chronic Care Clinic c) Health Center IV District Name Ntungamo Isingiro Mbarara

ix d) Medical Equipment and Furniture 02 INSTITUTIONAL FRAMEWORK Policy Framework: Legal Framework: Institutional Framework: World Bank Group Guidelines: General EHS Guidelines (April 30, 2007)”, x

03 ANALYSIS OF ALTERNATIVES i) “No- Action” Scenario ii) “Action” Scenario iii) Stack Design for Small Incineration Units 04 POTENTIAL SOCIO-ENVIRONMENTAL IMPACTS A) CONSTRUCTION-PHASE IMPACTS POSITIVE IMPACTS :

Income to material/ equipment suppliers and contractors NEGATIVE IMPACTS

Occupational health safety (OHS) Risks for Contractors xi

Impact mitigation Injury to patients or healthcare staff by construction activities Impact mitigation

Indoor air quality deterioration due to dust Impact mitigation Traffic accidents xii

Impact mitigation Improper management of demolition (and general construction) waste Impact mitigation Impact management Temporary disruption of healthcare services

Impact mitigation Impact management xiii

Social misdemeanor by construction workers Impact mitigation Impact management Impact of material transport Mitigation

Impact management Temporary scenic blight Mitigation

xiv

Impact management B) OPERATION-PHASE IMPACTS POSITIVE IMPACTS Improved medical services at healthcare facilities Enhancement measures

Improvement in livelihoods and local economies Employment opportunities Reduced public risks due to improvement in healthcare waste management xv

Enhancement measure Improved aesthetics and life of healthcare facilities

Enhancement measure NEGATIVE IMPACTS Air pollution from onsite incinerators Mitigation Impact management Engineering design EHS Guidelines: Air emissions and ambient air quality, April 2007 Inspection/ monitoring: Training Community health risk due to improper waste management Impact mitigation

1 MoH 2005 (revised march 2009): Improvement of healthcare waste management in Uganda (conducted by Carl Bro) xvi

Occupational health and safety risks Impact mitigation Fire Safety Impact mitigation Impact management Misuse or inability to use installed equipment Impact management xvii

Not maintaining improved facilities Impact management ENVIRONMENTAL-SOCIO MANAGEMENT PLAN (ESMP) xviii

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements 6.2 CONSTRU CTION PHASE 6.2.1 Positive impact Income to equipment ad material suppliers 6.2.2 Negative impacts OHS risk s to construction workers (hence $10,000 for 5 HCFs) Injury to patients or healthcare workers by construction activities xix

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements (hence $2500 for 5 HCF sites). Improper management of demolition (and general construction) waste ⇒⇒⇒ 1-year total for 5 HCFs: $6000

xxi

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements Temporary disruption of healthcare services Social misdemeanor by construction workers (hence $3000 for 5 HCF sites) Impact of material transport

xxii

6.3.1 Positive impacts Improved medical services at healthcare facilities Reduced public risks due to improvement in healthcare waste management (including incineration)

xxiii

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements Hence $40000 for 4 HCIV in this lot and $15000 for 1 hospital in this lot. ⇒⇒⇒ total for 4 annual audits: USD220,000 6.3.2 Negative impact s Air pollution due to improperly designed incinerator stacks (hence $5000 for 5 training sites) Community health risk due to improper waste management

xxiv

xxv

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements (Provide 2 units per HCIV hence $800 for 4 HCs and 6 units or $1200 for 1 hospital). ⇒⇒⇒ Total: $2000 Misuse or inability to use insta lled equipment TOTAL COST $271,000

xxvi

Conclusion

1 Introduction 1.1 Health Situation in Uganda and Project Background

Data are for 2006. (Source: World Health Statistics 2008 : www.who.int/whosis/en/index.html)

Uganda Health Systems Strengthening Project Health Infrastructure

Air Water Earth (AWE) 1.2 Proposed Renovations Government-funded private not-for-profit facilities private for-profit or commercial health units

1 MoH, 2009: Uganda Health Systems Strengthening Project: Concept Paper Prepared for World Bank Funding.

1.2.1 Regional Referral Hospital (RRH)

1.2.2 General Hospitals (GH) Category 1: Category 2 Category 3: Category 4: Chronic Care Clinic

1 NRH are Mulago, Butabika and recently elevated Gulu and Mbarara Hospitals .

Category 1 : Category 2 : Category 3 : Category 4 :

, Mityana, Nakaseke, Masindi Kiryandongo

1.2.3 Health Center IV (HC IV) District Name of HC IV facility 1.2.4 Medical Equipment and Furniture 1.3 Justification of the Proposed Project 1.4 Outline of Implementation Phases

Construction: Operation: 1.5 Study Objectives 1.5.1 Study Scope

1.5.1.1 Environmental Impact Assessment (EIA)

1.5.1.2 Social Impact Assessment (leading to ARAP) Abbreviated Resettlement Plan (ARAP) 1.6 Categorization of Project Facilities Central Region, (Volume 1) Eastern Region (Volume 2) Northern Region (Volume 3) Western Region (Volume 4) Western Region

District Healthcare facilities Mbarara Ntungamo Isingiro

2 Site Profiles and Existing Situation 2.1 Profiles of Project Areas and Sites 2.1.1 Itojo Hospital 2.1.1.1 Profile of Ntungamo District County or subcounty Households Male Female Total Average household size Bwong yera Ihunga Kibatsi Nyabihoko Itojo Ntungamo Ntungamo T.c Nyakyera Ruhaama Rukoni Rweikiniro Kayonza Ngoma Rubaare Rugarama Source: Population & Housing Census, 2002. Social economic factors: Education and literacy:

Social services:

2.1.1.2 Observations at Itojo Hospital

2.1.1.3 Observations at Rubaare HC IV

2.1.1.4 Observations Kitwe HC IV

2.1.2 Kabuyanda Health Center IV 2.1.2.1 Profile of Insingiro District

County or sub Households Male Female Total Average county household size Endizi Kashumb a Ngarama Rugaaga Birere Kabingo Kabuyanda Kikagate Masha Nyakitunda 1

1 .

2.1.2.2 Observations Kabuyanda HC IV

2.1.3 Mwizi Health Center IV 2.1.3.1 Mbarara District Profile

County or sub Households Male Female Total Average county household size Bubaare Bukiro Kagongi Kakiika Kashare Rubaya Rubindi Rwanyamahembe Kakoba Kamukuzi Nyamitanga Bugamba Mwizi Ndaiga Nyakayojo Rugando 2.1.3.2 Observations at Mwizi HC IV

2.2 HCW Incineration in Uganda: Concerns and Improvement Measures 2.2.1 HCWM Improvement Study (Carl Bro, Jul 2005, revised Mar 2009) Poor design and construction Improper location : Poor operation by untrained staff Incineration units commonly not fenced off

non- significant WBG EHS Guidelines for healthcare facilities (Apr 2007, page 6) Combustion chamber

Chimney (or stack): 2.2.2 UPOPs Inventory Report (“NEMA Study”) In 2005, The Ministry of Environment of Germany, where there were 66 incinerators at that time, estimated that "...whereas in 1990, 33% of all dioxin emissions in Germany came from incineration plants, in 2000 the figure was less than 1 %. Chimneys and tiled stoves in private households alone discharge approximately twenty times more dioxin into the environment than incineration plants 1.

According to United States Environmental Protection Agency (USEPA), incineration plants are no longer significant sources of dioxins and furans. In 1987, before government regulations required use of emission controls, there was a total of 10,000 grams of dioxin emissions from USA incinerators. Today, total emissions from the 87 incineration plants are only 10 grams yearly, a reduction of 99.9 %. Studies conducted by the USEPA 2 demonstrate that the emissions from just one family using a burn barrel produces more dioxin emissions than an incineration plant disposing of 200 metric tons of waste per day.

a) Emissions to air: Total annual medical waste incinerated: 102 tons/year Emission Factor (EF) for realise to air: 40,000 µg TEQ/tonne Potential releases to air (using above EF) is: 102 * 40,000 = 4,080,000 µg TEQ/year = 4.08 g TEQ/year b) Release to residues: Total annual medical waste incinerated: 102 tons/year EF for release to residue: 200 µg TEQ/tonne Thus, releases to residues (using above EF) is: 102 *200 = 20,400 µg TEQ/ year = 0.02 g TEQ/year

Total annual release from HCW incineration = 4.10 g TEQ/year Source: UPOPS study 2007, pg 34. 2.2.2.1 BAT/BEP Recommendations to Improve HCW Incineration Best Available Technologies (BAT), and, Best Environmental Practices (BEP).

a) Combustion technology and practices b) Operation of the incinerator c) Material input: waste quality and amount

2.2.3 Evaluation of existing incinerator types Conclusion and recommendation

2.2.4 Securing Incineration License from NEMA

The National Environment (Waste Management) Regulations, 1999 “13. (1) A person intending to operate a waste treatment plant or disposal site shall apply to the Authority for al license in Form V set out in the First Schedule and shall accompany the application with appropriate fee prescribed in the Sixth Schedule.

(3) A person who operates a waste treatment or disposal site or plant without a license issued under these Regulations commits an offence.”

3 ESIA Methodology

3.1 Determination of Baseline Conditions 3.2 Clarifications by Client Issue Clarification Mubende Moroto

Issue Clarification

centralized

Digital noise meter High Volume Air Sampler for dust measurement. A digital 6 -gas iTX meter used to measure prevailing air quality (NOx and SOx, H 2S, Carbonmonoxide). Plate 5: 3.3 ESIA Methodology

3.3.1 Acquainting with proposed works 3.3.2 Establishment of baseline socio-environmental conditions

3.3.3 Analyze specifications of incinerators, installation and operational concerns 3.3.4 Review of policy, regulations, institutional framework 3.3.5 Guidance on obtaining licenses to operate onsite waste treatment plant 3.3.6 Assessment of requirements for adequate and environmentally safe solid and liquid waste management at healthcare facilities

3.4 Impact Identification and Analysis consequence likelihood Precautionary Principle

4 Policy, Legal and Institutional Framework

4.1 Policy Framework 4.1.1 The National Environment Management Policy, 1994 4.1.2 The National Medical Equipment Policy, 2009

4.1.3 The National Health Policy, 1999 4.1.4 National Policy on Injection Safety and Health Care Waste Management, 2004 4.2 Legal Framework 4.2.1 Constitution of the Republic of Uganda, 1995 4.2.2 National Environment Act, Cap 153 in-situ ex-situ

Third Schedule

DEVELOPER INPUTS/OUTPUTS SCREENING

EIA STUDY

MAKING - DECISION

*Source: Appendix C (EIA Process in Uganda) of EIA Reference Manual, NEMA, June 2002) 4.2.3 Land Act, Cap 227

4.2.4 Local Governments Act, Cap 243 4.2.5 Public Health Act, Cap 281 4.2.6 National Environment (Standards for Discharge of Effluent into Water or on Land) Regulations, 1999 Parameter National discharge standards µ Source: The National Environment (Standards for Discharge of Effluent into Water or on Land) Regulations, 1999.

4.2.7 National Environment (Noise Standards and Control) Regulations, 2003 Facility Noise limits dB (A) (Leq) Day* Night* Source: The National Environment (Noise Standards and Control) Regulations, 2003. 4.2.8 National Environment (Waste Management) Regulations, 1999 4.2.9 Draft National Air Quality Standards, 2006 Pollutant Averaging time for ambient air Standard for ambient air

µ µ 4.2.10 Employment Act, 2006

4.2.11 Occupational Safety and Health Act (2006)

4.3 Institutional Framework 4.3.1 National Environmental Management Authority (NEMA) Environmental Liaison Units

4.3.2 Ministry of Health (MoH)

4.3.3 Ministry of Gender, Labor & Social Development 4.3.4 District Local Administration Structures

4.4 World Bank Group Guidelines 4.4.1 World Bank Operating Policies

(1) http://lnweb18.worldbank.org/ESSD/envext.nsf/47ByDocName/ToolsEnvironmentalAssessmentSourcebookandUpdates

4.4.2 WB Guidelines General EHS Guidelines (April 30, 2007)”, 1. Environmental 2. Occupational Health and Safety 3. Community Health and Safety

Construction and Decommissioning

4.4.1.1 WBG EHS Guidelines: “Air emissions and ambient air quality” a) General approach

non-significant

1 Significant 2

non-significant b) Emissions control recommendations Figure 2 c) Implication for this project

1 WBG EHS Guidelines: “Healthcare facilities” 2

Source: (WBG EHS Guidelines, April 2007, pg16)

4.4.1.2 WBG EHS Guidelines: “Waste management” a) General approach conventional hazardous waste b) Implication for this project 4.4.1.3 WBG EHS Guidelines: “Healthcare facilities” a) Applicability

b) Healthcare facility design considerations 1 c) Waste management

American Institute of Architects (AIA) Facility Guidelines Institute (FGI) American Society for Healthcare Engineering (ASHE) American Hospital Association (AHA) Green Guide for Healthcare

d) Occupational health and safety

Occupational Safety and Health Administration OSHA

Type of waste Summary of treatment and disposal options / notes Infectious waste: Includes waste suspected to contain pathogens (e.g. Waste Segregation Strategy : Yellow or red colored bag / container, marked “infectious” with international infectious symbol. Strong, leak proof bacteria, viruses, parasites, or fungi) in sufficient concentration or quantity plastic bag, or container capable of being autoclaved. to cause disease in susceptible hosts. Includes pathological and anatomical material (e.g. tissues, organs, body parts, human fetuses, Treatment : Chemical disinfection; Wet thermal treatment; Microwave irradiation; Safe burial on hospital premises; Sanitary landfill; Incineration animal carcasses, blood, and other body fluids), clothes, dressings, (Rotary kiln; pyrolytic incinerator; single-chamber incinerator; drum or brick incinerator) equipment / instruments, and other items that may have come into contact with infectious materials. • Highly infectious waste, such as cultures from lab work, should be sterilized using wet thermal treatment, such as autoclaving. • Anatomical waste should be treated using Incineration (Rotary kiln; pyrolytic incinerator; single-chamber incinerator; drum or brick incinerator).

Sharps: Includes needles, scalpels, blades, knives, infusion sets, saws, Waste Segregation Strategy : Yellow or red color code, marked “Sharps”. Rigid, impermeable, puncture -proof container (e.g. steel o r hard broken glass, and nails etc. plastic) with cover. Sharps containers should be placed in a sealed, yellow bag labeled “infectious waste”. Treatment : Chemical disinfection; Wet thermal treatment; Microwave irradiation; Encapsulation; Safe burial on hospital premises; Incineration (Rotary kiln; pyrolytic incinerator; single-chamber incinerator; drum or brick incinerator) • Following incineration, residues should be landfilled. • Sharps disinfected with chlorinated solutions should not be incinerated due to risk of generating POPs. • Needles and syringes should undergo mechanical mutilation (e.g. milling or crushing) prior to wet thermal treatment

Pharmaceutical waste: Includes expired, unused, spoiled, and Waste Segregation Strategy : Brown bag / container. Leak -proof plastic bag or container. contaminated pharmaceutical products, drugs, vaccines, and sera that Treatment : Sanitary landfillª; Encapsulationª; Discharge to sewer ª; Return expired drugs to supplier; Incineration (Rotary kiln; pyrolytic are no longer needed, including containers and other potentially incinerator ª); Safe burial on hospital premisesª as a last resort. contaminated materials (e.g. drug bottles vials, tubing etc.). • Small quantities: Landfill disposal acceptable, however cytotoxic and narcotic drugs should not be landfilled. Discharge to sewer only for mild, liquid pharmaceuticals, not antibiotics or cytotoxic drugs, and into a large water flow. Incineration acceptable in pyrolytic or rotary kiln incinerators, provided pharmaceuticals do not exceed 1 percent of total waste to avoid hazardous air emissions. Intravenous fluids (e.g. salts, amino acids) should be landfilled or discharged to sewer. Ampoules should be crushed and disposed of with sharps. • Large quantities: Incineration at temperatures exceeding 1200 °C. Encapsulation in metal drums. Landfilling not recommended unless encapsulated in metal drums and groundwater contamination risk is minimal.

Genotoxic / cytotoxic waste: Genotoxic waste m ay have mutagenic, Waste Segregation Strategy: See above for “infectious waste”. Cytotoxic waste should be labeled “Cytotoxic waste”. teratogenic, or carcinogenic properties, and typically arises from the feces, Treatment : Return expired drugs to supplier; Chemical degradation; Encapsulationª; Inertization; Incineration (Rotary kiln, pyrolytic incinerator); urine, and vomit of patients receiving cytostatic drugs, and from treatment • Cytotoxic waste should not be landfilled or discharged to sewer systems. with chemicals and radioactive materials. Cytotoxic drugs are commonly • Incineration is preferred disposal option. Waste should be returned to supplier where incineration is not an option. Incineration should be used in oncology and radiology departments as part of cancer treatments. undertaken at specific temperatures and time specifications for particular drugs. Most municipal or single chamber incinerators are not adequate for cytotoxic waste disposal. Open burning of waste is not acceptable. Chemical waste: Waste may be hazardous depending on the toxic, Waste Se gregation Strategy : Brown bag / container. Leak -proof plastic bag or container resistant to chemical corrosion effects. corrosive, flammable, reactive, and genotoxic properties. Chemical waste Treatment : Return unused chemicals to supplier; Encapsulationª; Safe burial on hospital premisesª; Incineration (Pyrolytic incineratorª; may be in solid, liquid, or gaseous form and is generated through use of • Facilities should have permits for disposal of general chemical waste (e.g. sugars, amino acids, salts) to sewer systems. chemicals during diagnostic / experimental work, cleaning, housekeeping, • Small hazardous quantities: Pyrolytic incineration, encapsulation, or landfilling. and disinfection. Chemicals typically include formaldehyde, photographic • Large hazardous quantities: Transported to appropriate facilities for disposal, or returned to the original supplier using shipping arrangements chemicals, halogenated and nonhalogenated solvents, organic chemicals that abide by the Basel Convention. Large quantities of chemical waste should not be encapsulated or landfilled. for cleaning / disinfecting, and various inorganic chemicals (e.g. acids and alkalis).

Radioactive waste: Includes solid, liquid , and gaseous materials that Waste Segregation Strategy: Lead box, labeled with the radioactive symbol. have been contaminated with radionuclides. Radioactive waste originates Treatment : Radioactive waste should be managed according to national requirements and current guidelines from the International Atomic from activities such as organ imaging, tumor localization, radiotherapy, Energy Agency. IAEA (2003). Management of Waste from the Use of Radioactive Materials in Medicine, Industry and Research. IAEA Draft and research / clinical laboratory procedures, among others, and may Safety Guide DS 160, 7 February 2003.

Type of waste Summary of treatment and disposal options / notes include glass ware, syringes, solutions, and excreta from treated patients. Waste with high content of heavy metals: Batteries, broken Waste Segregation Strategy: Waste containing heavy metals should be separated from general health care waste. thermometers, blood pressure gauges, (e.g. mercury and cadmium Treatment : Safe storage site designed for final disposal of hazardous waste. content). • Waste should not be burned, incinerated, or landfilled. Transport to specialized facilities for metal recovery.

Pressurized containers: Includes containers / cartridges / cylinders for Waste Segregation Strategy: Pressurized containers should be separated from general health care waste. nitrous oxide, ethylene oxide, oxygen, nitrogen, carbon dioxide, Treatment : Recycling and reuse; Crushing followed by landfill compressed air and other gases. • Incineration is not an option due to explosion risks • Halogenated agents in liquid form should be disposed of as chemical waste.

General health care waste (including food waste and paper, plastics, Waste Segregation Strategy : Black bag / c ontainer. Halogenated plastics such as PVC should be separated from general health care facility cardboard) : waste to avoid disposal through incineration and associated hazardous air emissions from exhaust gases (e.g. hydrochloric acids and dioxins). Treatment: Disposal as part of domestic waste. Food waste should be segregated and composted. Component wastes (e.g. paper, cardboard, recyclable plastics [PET, PE, PP], glass) should be segregated and sent for recycling where available.

Source : Safe Management of Wastes from Health -Care Activities. International Labor Organization (ILO), Eds. Pruss, A. Giroult, and P. Rushbrook (1999) Notes: a. Small quantities only

48 e) Air emission levels for hospital waste incineration facilities Pollutant Unit Guideline value Notes:

4.4.1.4 WBG EHS Guidelines: “Hazardous materials management” a) Application and approach b) General hazardous materials management

4.4.1.5 WBG EHS Guidelines: “Construction and decommissioning”

Environment: Noise and Vibration: Air Quality: Solid Waste: Occupational Health and Safety Community Health and Safety:

General site hazards Disease Prevention Traffic Safety:

4.4.2 Comparison of Uganda Standards and WBG Requirements

Issue Uganda requirement IFC World Bank requirement Social and The Environmental National Environment Act Assessment (Cap 153) and Management System Involuntary Resettlement Healthc are Waste www.ifc.org/ifcext/enviro.nsf/Content/EnvironmentalGuidelines) Management Incineration and emissions “Environmental, Health and Safety control Guidelines-HEALTHCARE FACILITIES”. AIR EMISSIONS AND AMBIENT AIR QUALITY “Environmental, Health and Safety Guidelines- HEALTHCARE FACILITIES

Issue Uganda requirement IFC World Bank requirement Air quality significant standards

5 Analysis of Alternatives 5.1 “No- Action” Scenario 5.2 “Action” Scenario 5.3 Power Supply 5.4 Stack Design for Small Incineration Units

6 Potential Socio-Environmental Impacts 6.1 Introduction “Positive” “Negative” “First order” “Second order” “Third order” “Reversible” “Irreversible” “Short-term” “Medium-term” “Long-term” 6.2 Construction-Phase Impacts 6.2.1 Positive impacts 6.2.1.1 Income to material/ equipment suppliers and contractors Enhancement measure

6.2.2 Negative impacts 6.2.2.1 Occupational health safety (OHS) Risks for Contractors

Impact identification

Impact evaluation Impact severity medium high

Impact significance

Significance Significance Value Significance color code Rating level of this impact √ Impact mitigation

Objective Workplace h azards Suggested PPE

Impact management 6.2.2.2 Injury to patients or healthcare staff by construction activities

Impact identification

Impact evaluation Impact severity medium

high Impact significance Significance Significance Value Significance color code Rating level of this impact √

Impact mitigation

Impact management 6.2.2.3 Indoor air quality deterioration due to dust Impact identification

Impact evaluation Impact severity high high Impact significance

Significance Significance Value Significance color code Rating level of this impact √

Impact mitigation

Impact management

6.2.2.4 Traffic accidents

Impact identification

Impact evaluation Impact severity high high Impact significance Significance Significance Value Significance color code Rating level of this impact √ Impact mitigation

Impact management 6.2.2.5 Improper management of demolition (and general construction) waste Impact identification

Impact evaluation

Impact severity high high

Impact significance Significance Significance Value Significance level color code Rating of this impact √ Impact mitigation Impact management 6.2.2.6 Temporary disruption of healthcare services

Impact identification Impact evaluation Impact severity high medium-high

Impact significance Significance Significance Value Significance color code Rating level of this impact √ Impact mitigation Impact management 6.2.2.7 Social misdemeanor by construction workers Impact evaluation Impact severity high high

Impact significance Significance Significanc e Value Significance color code Rating level of this impact √ Impact mitigation Impact management 6.2.2.8 Impact of material transport Impact identification Impact evaluation Impact severity

low-medium Impact significance Significance Significance Value Significance color code Rating level of this impact √ Mitigation Impact management 6.2.2.9 Temporary scenic blight Impact identification Impact evaluation Impact severity low

Impact significance Significance Significance Value Significance color code Rating level of this impact √ Mitigation Impact management 6.3 Operation Phase Impacts 6.3.1 Positive impacts 6.3.1.1 Improved medical services at healthcare facilities Enhancement measures

6.3.1.2 Improvement in livelihoods and local economies

Enhancement measure 6.3.1.3 Employment opportunities 6.3.1.4 Reduced public risks due to improvement in healthcare waste management Enhancement measure Environmental Impact Assessment Regulations, 1998” 31.(2) Within a period of not less than 12 months and not more than 36 months after completion of a project or commencement of its operations, whichever is earlier, the developer shall undertake an initial environmental audit of the project.

6.3.1.5 Improved aesthetics and life of healthcare facilities

Plate 8: Enhancement measure 6.3.2 Negative impacts

6.3.2.1 Air pollution from onsite incinerators Impact identification

Impact evaluation Impact severity WBG EHS Guidelines: “Air emissions and ambient air quality” high Impact significance Significance Significance Value Significance color code Rating level of this impact √ Mitigation Impact management Engineering design EHS Guidelines: Air emissions and ambient air quality, April 2007 Inspection/ monitoring: Training

6.3.2.2 Community health risk due to improper waste management Impact identification Impact evaluation

Impact severity high high Impact significance Significance Significance Value Significance color code Rating level of this impact √ Impact mitigation

Impact management

1 MoH 2005 (revised march 2009): Improvement of healthcare waste management in Uganda (conducted by Carl Bro)

6.3.2.3 Occupational health and safety risks Impact identification 1:

1 World Health Organization (WHO) Classification of Infective Microorganisms by Risk Group (2004).

4: Impact evaluation Impact severity high high Impact significance Significance Significance Value Significance color code Rating level of this impact √ Impact mitigation prevention

Exposure Workers (min imum 19 years of age)

Impact management

6.3.2.4 Fire risk

Impact identification Impact evaluation Impact severity medium-high high Impact significance Sig nificance Significance Value Significance color code Rating level of this impact √ Impact mitigation Impact management 6.3.2.5 Misuse or inability to use installed equipment

Impact identification

Impact mitigation

Impact management

6.3.2.6 Not maintaining improved facilities

Impact mitigation Impact management

7 Impact Monitoring & Management Plan 7.1 Institutional arrangements a) Institutional structure and responsibilities

b) Monitoring and reporting arrangements

Who monitors and how: ad hoc

Frequency: Audits: 1 year’s

Reporting: 7.2 Grievance mechanism Step 1: Receipt of complaint

Step 2: Determination of corrective action Step 3: Meeting with the complainant Step 4: Implementation of corrective action

Step 5: Verification of corrective action

Step 6: Action by MoH and project contractors

Key:

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements 6.2 CONSTRUCTION PHASE 6.2.1 Positive impact Income to equipment ad material suppliers 6.2.2 Negative impacts OHS risk s to construction workers (hence $10,000 for 5 HCFs) Injury to patients or healthcare workers by construction activities

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements (hence $2500 for 5 HCF sites). Improper management of demolition (and general construction) waste ⇒⇒⇒ 1-year total for 5 HCFs: $6000

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements Temporary disruption of healthcare services Social misdemeanor by construction workers (hence $3000 for 5 HCF sites) Impact of material transport

6.3.1 Positive impacts Improved medical services at healthcare facilities Reduced public risks due to improvement in healthcare waste management (including incineration) Hence $40000 for 4 HCIV in this lot and $15000 for 1 hospital in this lot. ⇒⇒⇒ total for 4 annual audits: USD220,000 6.3.2 Negative impact s

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements Air pollution due to improperly designed incinerator stacks (hence $5000 for 5 training sites) Community health risk due to improper waste management Occupational health and safety risks

Impact and Monitoring: Performance Incremental Capacity Building Text Reference Mitigation/Enhancement Desired Outcomes Indicators/Targets or Timing Responsibility Costs (USD) for and Training commitments Acceptance Criteria all HCFs sites Requirements Fire risk (Provide 2 units per HCIV hence $800 for 4 HCs and 6 units or $1200 for 1 hospital). ⇒⇒⇒ Total: $2000 Misuse or inability to use installed equipment TOTAL COST $271,000

8 Conclusion

9 Abbreviated Resettlement Action Plan (ARAP)

Bibliographies Environmental Impact Assessment Guidelines for Uganda.

Appendices Appendix 1: Record of stakeholder consultations Issues raised:

Issues raised :

Issues raised:

Appendix 2: Measured baseline (air quality, noise) conditions Table A1: Daytime ambient noise recorded

District Healthcare facility Noise Time Remarks measurement (dBA) Min Max Ntungamo Mbarara Insingiro

Table A2: Levels of toxic gases measured at the different healthcare facilities

District Healthcare Gas con centration facility

CO NO 2 LEL SO 2 O (%) µ µ µ 2 µ Apac Mbarara Insingiro

Parameter WHO guidelines µ µ µ µ µ µ

PM 10 : Particulate matter of size range 2.5-10 µm

Appendix 3: Evaluation of incinerator types Incinerator HWI -4 Maximaster MKII MAK IV Criteria Main combustion zone (Incineration temperature) Number of combustion chambers Capacity Fuel/Energy consumption Heat insulation Scrubbing ability Stack/chimney height Charge/Feed operation Limitation on materials to be incinerated

Evaluation • • • • • • • • •

Incinerator HWI -4 Maximaster MKII MAK IV • • Final Assessment

Appendix 4: Sketch maps of HCFs

MWIZI HEALTH CENTER IV

N To Mbarara

OPD

Pit Latrines

Theatre Doctor’s House

Generator Pit Latrines Placenta Pit

Pit Latrines

e c n a t r Store New OPD n E i n a

M s

Old OPD e

a s ffice L

i Ward

n e

T h e a t r e c

N l

i P

Pit Latrines P i t L a t r i n e s

KITWE HEALTH CENTER IV

Pit Latrine

Theatre

Pit Latrine

ng si ou Placenta Pit H

ine ff Pit Latr ta S

y H/Q b Count aare Su To Rub

a i n

E n t r a n c e OPD General Ward Paediatric Ward g n si u o H ff ta Office S Theatre N Mortuary

Placenta Pit

Appendix 5: Environmental clauses for construction contracts

General Environmental Management Conditions for Construction Contracts General

Worksite/Campsite Waste Management

Material Excavation and Deposit

Rehabilitation and Soil Erosion Prevention

Water Resources Management

Traffic Management

Blasting Disposal of Unusable Elements Health and Safety Repair of Private Property Contractor’s Health, Safety and Environment Management Plan (HSE-MP) • • • • • • HSE Reporting

• • • • •

Training of Contractor’s Personnel • • •

HIV/AIDS

Cost of Compliance

Example Format: HSE Report

Contract: Period of reporting: HSE management actions/measures:

HSE incidents:

HSE compliance:

Changes:

Concerns and observations:

Signature (Name, Title Date):

100

Example Format: HSE Incident Notification

Originators Reference No: Date of Incident: Time:

Location of incident:

Name of Person(s) involved:

Employing Company:

Type of Incident:

Description of Incident:

Immediate Action: Signature (Name, Title, Date):

101

Appendix 6: Terms of Reference TERMS OF REFERENCE FOR ENVIRONMENTAL AND SOCIAL IMPACT ASSESSMENT OF THE UGANDA HEALTH SYSTEMS STRENGTHENING PROJECT. 1.0 Introduction 2.0 Project Objectives 2.1 Specific objectives of the project 3.0 Project components

102

4.0 Objectives of the Consultancy

4.1 4.2 5.0 Detailed Scope of Services A. Environmental Impact Assessment (EIA)

103

B Social Impact Assessment Hospitals HCIVs

104

6.0 Reports and Time Schedules 6.1 Draft inception report 6.2 Final inception report 6.3 Draft Environmental and Social Impact Assessment Report 6.4 Final Environmental and Social Impact assessment report 7.0 Staffing 1. Environmental Consultant

105

2. Sociologist 3. Environmental/Sanitary Engineer

8.0 Data, Services, Personnel and facilities to be provided by the Client