E1543 V2 ARMENIA HEALTH SYSTEM MODERNIZATION PROJECT

Public Disclosure Authorized Public Disclosure Authorized

ENVIRONMENTAL IMPACT ASSESSMENT REPORT

Public Disclosure Authorized AND ENVIRONMENTAL MANAGEMENT PLAN

FOR CONSTRUCTION OF MULTI-PROFILE HOSPITAL IN GYUMRl CITY, SHIRAK REGION

Public Disclosure Authorized

Date: June 2010 Construction of multi-profile hospital in Gyumri city, Shirak region

TABLE OF CONTENTS

TABLE OF CONTENTS 2 1. Executive Summary 3 2. Introduction 6 3. Policy, Legal and Administrative Framework 8 3.1 Policy and Legal Framework 8 3.2 Administrative Framework 17 4. Project Description 19 5. Description of the Project Environment 24 7. Potential Impacts and Mitigation Measures 32 7.1 Expected Short Term Environmental and Social Impacts 33 7.2 Expected Long Term Social and Environmental Impacts 36 7.3 Mitigation Measures 37 8. Public Consultations 41

ANNEX I. REFERENCE LIST 42

ANNEX II. ENVIRONMENTAL MANAGEMENT PLAN 45 Mitigation and 45 Monitoring Plans 45 Estimated Cost 45 Implementation Schedule and Reporting 46 Remedies for EMP Violation 46 TABLE 1. Mitigation Plan 48 TABLE 2. Monitoring Plan 52 TABLE 3. Accident Report Form 55

ANNEX III. MINUTES OF PUBLIC CONSULTATION 56

Environmental Impact Assessment and Environmental Management Plan Reports 2 Construction of multi-profile hospital in Gyumri city, Shirak region

1. Executive Summary

The Health System Modernization Project (APL2) is the second phase of a two-phase Adaptable Lending Program (APL) to support Armenia’s health sector reform program. The objective is to improve the organization of the health care system in order to provide more accessible, quality and sustainable health care services to the population, in particular to the most vulnerable groups. The project goals are: increasing utilization of essential health services closer to international benchmarks for countries with similar demographic and epidemiologic profiles; reducing differences in utilization of essential health care services between the poorest and richest income groups of population; improving the perceived quality and accessibility of health care services by the population; improvement in the efficiency of the allocation and use of public expenditures on health through rationalization of inputs on the supply side; improving health-related MDGs, mainly in infant mortality, maternal mortality and prevention and control of public health threats such as HIV/AIDS and Tuberculosis which are amenable to health sector interventions; and increasing transparency and performance in public hospitals as a result of the introduction of better management and fiduciary practices and performance-based payment mechanism.

The objectives of Armenia Health System Modernization Project 2 are to support completion of transition phase for providing family medicine services to whole population of Armenia, modernization of eight selected hospital networks in the regions, and improvement of the medical education system.

One of the main physical investments will be directed to construction of a new 200-bed adult multi-profile hospital in Gyumri city, Shirak region, within the premises of the existing Austrian children’s hospital of Gyumri, as stipulated by the revision of Government decree on regional hospital system optimization of December 2008. Construction of new adult hospital in Gyumri city will lead to closure of Shirak regional hospital, Gyulbenkyan Surgical hospitals, while Samariter hospital of Gyumri city will become rehabilitation center.

The baseline conditions of the project affected area were studied based on the results of the investigations conducted by design consultant as well as through studying available materials and literature.

This Environmental Impact Assessment document is aimed at providing a description of existing environmental situation in the project areas, identification of the relevant legal and administrative framework, revealing the potential beneficial and adverse impacts associated with project implementation and defining the measures that are appropriate to enhance the potential beneficial impacts and to prevent mitigate or minimize potential adverse impacts.

RA Law on Environmental Impact Assessment defines the types of planned activities subject to environmental impact assessment: In the town-planning sector the construction of buildings, constructions, complexes exceeding the threshold is subject to EIA (“thresholds” were set by the Governmental Decree N193 issued on March 30, 1999). Construction of a new hospital in Gyumri (including he boiler house) is subject to EIA (as it exceeds the threshold of 1000m2). According to the WB guidelines the project is classified under the Environmental Category B, hence requiring development and implementation of an Environmental Management Plan (EMP).

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“No Action” alternative is considered from the perspective of not developing the Project. The “No Action” alternative for the hospital construction would lead to insufficient provision of health care services on the basis of family medicine, further deterioration of hospital networks in the regions, as well as reduction of access to quality health care services provided to the population, in particular the most vulnerable groups.

The EIA process requires identification and assessment of all potential significant environmental effects arising from the proposed project. The methodology used in identifying the likely significant environmental effects of the proposed project included desk review of the existing available materials (design documents and available literature to collect the environmental baseline data) as well as field works conducted on proposed site (site-specific surveys conducted during design development) and public consultation.

The project is not expected to have significant or irreversible negative environmental impacts neither at the construction, nor at operation phases.

Impacts of the construction phase will be typical for all medium scale construction activities, short-term and limited to the project sites which are State owned land plots with user rights already granted to the medical institutions currently operating in these plots. Impacts of the operation phase will be typical for operating medical institutions. There are no specially protected areas or threatened or endangered endemic species in the project area.

The likely adverse environmental impacts during the construction phase will include the following: degradation of soil, landscape and soil erosion due to improper disposal of excavated materials and construction waste; spillage of oil and other substances during the construction; pollution of water resources and soil by construction run-offs; use of temporary construction sites (access roads, camps, machinery sites, storage facilities, etc); use of borrow pits; extraction of aggregate material, such as gravel, sand, rock; temporary air pollution related to increased truck traffic during the construction, release of dust from digging-loading works and heavy machinery operation; noise and vibration disturbances; safety hazards during implementation of construction works. The likely adverse environmental impacts during the operation phase include: emissions to atmosphere associated with operation of heating system and subsequent emission of pollutants originated during burning of fuel; impacts on water and soil as a result of improper maintenance of water supply and wastewater system, drainage system, vehicles and equipment, boiler house and electrical sub-station, safety hazards associated with improper operation or absence of fire-fighting system; waste disposal issues associated with improper categorization and utilization/disposal of domestic and medical waste generated in the hospital. Among the long-term social impacts the followings shall be mentioned: provision of reliable, timely and high-quality primary health care services on the basis of family medicine; provision of a wide range of healthcare services in one medical center; improved access to quality health care services provided to the population, in particular the most vulnerable groups; reduction of hospital operation and maintenance costs; creation of new employment opportunities; overall improvement of the socio- economic situation and population welfare.

The likely adverse impacts mentioned above can be prevented, minimized and additional loads on natural resources can be minimized by timely and due implementation of mitigation measures provided in the Environmental Management Plan (EMP). These measures specifically developed for the construction phase of the project include: use

Environmental Impact Assessment and Environmental Management Plan Reports 4 Construction of multi-profile hospital in Gyumri city, Shirak region existing quarries, borrow sites, waste disposal sites and avoid opening of new ones, obtain all required agreements and permits in case of opening a new quarry as well as for waste disposal; use the existing access roads avoiding construction of new ones; carefully delineate all access roads, work sites, construction materials storage, waste temporary accumulation sites and monitor these sites closely so that they do not expand unduly during construction; scrap the top layer of soil in the areas designated for establishment of construction camps/storage sites and store it in piles for further restoration of site; compact the top surface of access roads and work sites to facilitate water runoff and avoid flooding the area; conduct dust-depressing measures aimed at prevention of air pollution; use closed/covered trucks for transportation of loose construction materials; regular check of proper technical conditions of machinery and equipment; disposal of excavated materials and construction waste in agreed disposal sites; ban disposal of waste into waterways, their beds, wetlands, flood plains, or in immediate proximity to them. Where possible; restoration to quasi-original conditions of landscape after completion of construction works; use of appropriate safety uniform by personnel involved in construction works.

Mitigation measures proposed for the operation phase include: proper maintenance of water supply and wastewater system; regular check of proper technical conditions of vehicles and equipment; proper maintenance of boiler house; ensure presence and working condition of fire-fighting equipment, proper disposal of domestic and medical waste. Proper and timely implementation of the proposed mitigation measures regularly monitored according to the Monitoring Plan.

Overall, the positive socio-economic and environmental impacts of the construction of a new 200-bed adult multi-profile hospital in Gyumri city will greatly overweight the potential environmental risks, since it will allow to expand primary health care services on the basis of family medicine, to upgrade hospital networks in the regions, to improve access to quality health care services provided to the population, in particular the most vulnerable groups.

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2. Introduction The Armenia Health System Modernization Project 2 is the second phase of a two-phase Adaptable Lending Program to support Armenia’s health sector reform program. The objective is to improve the organization of the health care system in order to provide more accessible, quality and sustainable health care services to the population, in particular to the most vulnerable groups. The project goals are: increasing utilization of essential health services closer to international benchmarks for countries with similar demographic and epidemiologic profiles; reducing differences in utilization of essential health care services between the poorest and richest income groups of population; improving the perceived quality and accessibility of health care services by the population; improvement in the efficiency of the allocation and use of public expenditures on health through rationalization of inputs on the supply side; improving health-related MDGs, mainly in infant mortality, maternal mortality and prevention and control of public health threats such as HIV/AIDS and Tuberculosis which are amenable to health sector interventions; and increasing transparency and performance in public hospitals as a result of the introduction of better management and fiduciary practices and performance-based payment mechanism.

The objectives of Armenia Health System Modernization Project 2 are to support completion of transition phase for providing family medicine services to whole population of Armenia, modernization of eight selected hospital networks in the regions, and improvement of the medical education system.

The above objectives will be achieved through: (i) retraining additional number of family physicians and family nurses; (ii) strengthening Primary Health Care infrastructure; (iii) optimizing and upgrading the regional hospital networks buildings, providing with essential medical equipment, strengthening of hospital management structures, improving the health care waste management practices, and providing waste management supplies, and (iv) improving the systems of undergraduate and postgraduate medical education.

The immediate impact of the activities supported by the scaled-up project on the environment would be limited. The main physical investments will be directed to: • Rehabilitation and refurbishment of 7 selected regional hospital networks of Armenia included in the optimization plans adopted by the Government of the Republic of Armenia (RA) in the beginning of November 2006. Construction of an additional hospital block (about 1000 square meters) for the Goris Medical Center, Syunik region, and extension of the central block of Gavar Medical Center, Gegharkunik region to room emergency & admissions, operating theatres’, and delivery departments as advised by international hospital designer and planner experts. • Construction of a new 200-bed adult multi-profile hospital in Gyumri city, Shirak region, within the premises of the existing Austrian children’s hospital of Gyumri, as stipulated by the revision of Government decree on regional hospital system optimization of December 2008. • Rehabilitation of 30 selected Primary Health Care Centers in regions; • Construction of 20 new Primary Health Care Centers in selected regions;

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The project is designed for implementation over a period of 4 years, beginning from July 2007 and estimated to end in June 2012. The Ministry of Health (MOH) is designated by the Government as the responsible agency for the project. The Ministry is supported by the Health Project Implementation Unit (HPIU) - the coordination unit for the on-going Armenia Health System Modernization Project.

Besides the MOH and the HPIU, the Ministry of Finance, the State Health Agency, the National Institute of Health, and regional (Marz) Health Departments, and the management teams of the beneficiary health facilities are the key participants in project implementation.

To coordinate and supervise the project, the MOH established a Coordination Board consisting of representatives of the key stakeholders within and external to the Ministry for the purposes of guiding and coordinating the policy of optimizing the health sector. In addition to the general discussion of policy, the Board (or by decision of the Board, certain members) will be involved in such issues as defining terms of references, participating in technical evaluations, and working directly with consultants for the strategic technical assistance assignments.

One of the main physical investments will be directed to construction of a new 200-bed adult multi-profile hospital in Gyumri city, Shirak region, within the premises of the existing Austrian children’s hospital of Gyumri, as stipulated by the revision of Government decree on regional hospital system optimization of December 2008.

The purpose of the current Environmental Impact Assessment document is to provide a description of existing environmental situation in the project area, identify the relevant legal and administrative framework, reveal potential beneficial and adverse impacts associated with project implementation and define the appropriate measures that are appropriate to enhance the potential beneficial impacts and to prevent, mitigate or minimize potential adverse impacts.

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3. Policy, Legal and Administrative Framework 3.1 Policy and Legal Framework

3.1.1 Local Legislation The declaration on state independence of the Republic of Armenia (RA) was adopted on 23rd of August 1990 and the referendum on independence declaration was held on 21st of September 1991. On 21st of December of the same year Armenia became a member of the CIS, on 2nd of March 1992 – a Member of the United Nations, on 25th of January 2001 – a member of the Council of Europe and on 5th of February 2003 – a member of the World Trade Organization. After Armenia gained its independence in 1991, the deteriorating environmental condition of the country became more apparent and environmental concerns became high priority political issues and the process of development of environmental legislation was initiated.

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

In parallel with economic development of the Republic, the directions of policies of environmental changes and the basis of environmental laws were changed. A number of legislative acts accepted in 90s that didn’t provide sustainable management of environmental maintenance and natural resource usage also undertook changes. The list of the regulating the fields of nature protection and health of the RA is presented below:

• Law on the Principles of Environmental Protection (1991); • Law on Ensuring Sanitary-epidemiological Security of the RA Population (1992); • Law on Atmospheric Air Protection (1994); • Law on Environmental Impact Assessment (1995); • Law on Medical Care and Services to the Population (1996) • Law on the Protection and Use of Fixed Cultural and Historic Monuments and Historic Environment (1998); • Law on Environmental and Nature Use Charges (1998); • Law on Flora (1999); • Law on Fauna (2000); • Land Code (2001); • Law on Environmental Education (2001); • Water Code (2002), (the first Code was adopted in 1992); • Code Underground (2002), (the first Code was adopted in 1992); • Law on Wastes (2004); • Law on Environmental Monitoring (2005); • Law on Environmental Oversight (2005); • Forest Code (2005), (the first Code was adopted in 1994);

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• Law on Rates of Environmental Charges (2006); • Law on Specially Protected Natural Areas (27.11.2006), (the first Law was adopted in 1991); In addition to the above laws the following norms, regulations and decrees are relevant to the project:

• Construction norms and regulations volume II-L.9-70 Hospitals & Polyclinics; • Construction norms and regulations 2.08.02-89 Public buildings; • Credit # 4267 - AM Financing Agreement on the Armenia Health System Modernization ( PL2) signed on March 9, 2007 between Government of RA and the IDA; • Decree # 1911- N dated 02.11.06 of the Government of RA on “Optimization of the Marz Health Care Systems.

Summaries of the laws from the list which are most relevant to the current assignment are presented below.

Law on the Principles of Environmental Protection (1991) The Law on the Principles of Environmental Protection was adopted by the National Assembly (Parliament) in 1991. It outlines the environmental protection policy of the Republic of Armenia. Its purpose is to ensure state regulation of environmental protection and use within the territory of the republic. It provides a legal basis for the development of environmental legislation regulating the protection and use of entrails, forest, water, flora and fauna, and the atmosphere. This law also granted every citizen the right to demand and obtain reliable information on environmental conditions.

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

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

Environmental Impact Assessment and Environmental Management Plan Reports 9 Construction of multi-profile hospital in Gyumri city, Shirak region impact. The law defines the State control over the quality of ambient air, as well as the mechanisms for responsibilities for the violation of the provisions, reimbursement, etc.

The RA Government follows the RA Law “On Protection of Ambient Air” to approve the complex programs aimed at the protection of the ambient air, to define maximum permissible concentrations of air pollutants and the norms of possible physical negative impact on the atmosphere, as well as the procedure for state registration of pollution emissions.

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

Law on Environmental Impact Assessment (1995) The Armenian Law on Environmental Impact Assessment (EIA), passed in 1995, provides legal basis for implementation and introduction of state expertise of planned activities and concept frameworks as well as presents the standard steps of the EIA process for various projects and activities in Armenia. It establishes in Articles 2-5, the general legal, economic, and organizational principles for conducting mandatory state EIA of various types of projects and “concepts” of sectoral development (e.g., energy, mining, chemical industry, construction, metallurgy, pulp and paper, agriculture, food and fishery, water, electronics, infrastructure, services, tourism and recreation, etc.). The Law also stipulates provisions directly related to project sector, particularly in the Article 4 “Intended Activities Subject to Expertise” the Law enumerates the types of planned activities subject to environmental impact assessment: In the town-planning sector the construction of buildings, constructions, complexes exceeding the threshold is subject of environmental impact assessment (“thresholds” were set by the Governmental Decree N193 issued on March 30, 1999). Construction of hospital (including he boiler house) is subject to EIA (as it exceeds the threshold of 1000m2). The Law forbids any economic unit to operate or any concept, program and plan to be implemented without a positive conclusion of an EIA. In addition, an EIA may be also initiated for projects that do not meet the “threshold” requirements. According to the Article 4, such right was given to local authorities, ministries, local communities and NGOs. Other national legislation that determines the “special status” of a particular territory may also trigger a review of environmental impact. The Ministry of Nature Protection can initiate a review of environmental impact when it deems it to be necessary. The EIA Law specifies notification, documentation, public consultations, and appeal procedures and requirements. The Law on EIA law also provides for public involvement and participation. The Law demands that for the operation of any economic unit, or implementation of a plan or programs, a positive conclusion on an environmental impact assessment must be obtained from the State Environmental Expertise State Non Commercial Organization of the RA Ministry of Nature Protection.

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The Law on EIA is generally consistent with the EIA approaches followed by international conventions and development assistance agencies (e.g., World Bank, ADB, USAID, EU, etc.).

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

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

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

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

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

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

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

Following the requirements of this Code the regulations on “On establishment of technical regulations for requirements on re-cultivation and for classification of disturbed lands which are subject to re-cultivation” (dated 29.05.2006 N750-N) and “On establishment of technical regulations for general requirements for protection of lands from pollution, list of substances polluting the lands, and assessment of level of land pollution” (24.08.2006 N1277-N).

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

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Code on Underground (2002) The code defines principles, order of using the underground in the RA, the relations related to underground maintenance and usage, conditions and requirements of efficient usage, complex usage and maintenance of underground, provision of security to implement activities, and protecting the environment from negative impacts, as well as protection of rights of the state, citizens and underground users. According to the Code underground is under the state exclusive ownership, which can be given for usage for a certain period, and cannot be privatized. The law also determines conditions, requirements and peculiarities of the natural resources and underground maintenance. It also decides payment principles of underground consumers, compensation, monitoring, and types of limitation of underground resources utilization.

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

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

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

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3.1.2. Permits and agreements already obtained

• Cadastre certificate for the land plot to be used for hospital construction. Certificate No 2641909 was issued on 23 October 2009 by Gyumri regional department of State Committee on real Estate Cadastre. • Waste disposal agreement issued on 31 August 2009 by Gyumri City Hall department on Housing Communal Services and Environment Protection with respect to allocating the waste disposal site.

3.1.3. Permits and agreements required prior to commencement of construction works and during operation

• Positive conclusion issued by State Environmental Expertise SNCO of the Ministry of Nature Protection. Such conclusion is required to be obtained by HPIU in accordance with the Law on Environmental Impact Assessment. Article 4 “Intended Activities Subject to Expertise” of the Law enumerates the types of planned activities subject to environmental impact assessment: In the town-planning sector the construction of buildings, constructions, complexes exceeding the threshold is subject of environmental impact assessment (“thresholds” were set by the Governmental Decree N193 dated 30.03.1999). Construction of hospital (including the boiler house) is subject to EIA (as it exceeds the threshold of 1000m2); • Permit/license from the Ministry of Nature Protection and the Ministry of Energy and Natural Resources for the opening and operation of new quarries shall be obtained by the Construction Contractor, before commencement of construction activities. However, it is strongly recommended to avoid opening of new quarries, and use the existing quarries and borrow sites; • Agreement from the relevant local/regional authorities (usually community administration) for disposal of excavated materials and construction wastes in the approved dump site shall be obtained by Construction Contractor prior to transportation and disposal of construction concrete rubbles, debris and spoils as well as excessive excavation materials in such dump sites; • Compulsory payments for harmful substances emissions, surface and underground water pollution with wastewater, pollution of other components of environment are calculated and paid by Hospital administration in accordance with RA Law on Environmental and Nature Use Charges (28.12.1998) and RA Law “On Rates of Nature Protection Payments” (dated 19.04.2000).; • Develop draft MAC normative for medical centre and submit it to MNP for approval (this is a precondition for operation of boiler house).

3.1.4. International Agreements

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

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Convention or Protocol, NN In Force Signed Ratified Comment Name and Place Convention on Biological Diversity, Re-registered in 1 1993 1992 1993 (Rio-De-Janeiro, 1992) UN 1993 UN Framework Convention Re-registered in 2 1994 1992 1993 on Climate Change, (New-York, 1992) UN in 1993 3 Kyoto Protocol, (Kyoto, 1997) 2005 2002 Convention on Long-range Re-registered in Transboundary Air Pollution, 1983 1996 UN in 1997 (Geneva, 1979) Protocol on Persistent Organic 1998 4 Pollutants, (Aarhus, 1998) Protocol to Abate Acidification, Eutrophication and Ground-level 1999 Ozone, (Gothenburg, 1999) Convention on Environmental Impact Re-registered in Assessment in a Transboundary 1997 1996 UN in 1997 5 Context, (Espoo, 1991) Protocol on Strategic Environmental 2003 Assessment, (Kiev, 2003) UN Convention to Combat Re-registered in 6 1996 1994 1997 Desertification, (Paris, 1994) UN in 1997 Convention on the Control of Transboundary Movements of Re-registered in 7 1992 1999 Hazardous Wastes and Their UN in 1999 Disposal, (Basel, 1989) Convention for the Protection of the Re-registered in 1988 1999 Ozone Layer, (Vienna, 1985.) UN in 1999 8 Montreal Protocol on Substances that Re-registered in Deplete the Ozone Layer, 1989 1999 UN in 1999 (Montreal, 1987) Convention on Access to Information, Public Participation in Decision- 12 Making and Access to Justice in 2001 1998 2001 Environmental Matters, (Aarhus, 1998) Convention on the Prior Informed Consent Procedure for Certain 13 1998 2003 Hazardous Chemical and Pesticides in International Trade, (Rotterdam, 1998) Convention on Protection and Use of Trans-boundary Watercourses and 1996 1999 14 International Lakes, (Helsinki, 1992) Protocol on Water and Health, 1999 (London, 1999) Stockholm Convention on Persistent 15 2004 2001 2003 Organic Pollutants, (Stockholm, 2001)

Environmental Impact Assessment and Environmental Management Plan Reports 15 Construction of multi-profile hospital in Gyumri city, Shirak region

3.1.5. The World Bank Safeguard Policies The World Bank’s OP 4.01 Environmental Assessment is considered to be the umbrella policy for the Bank’s environmental safeguard policies. These policies are critical for ensuring that potentially adverse environmental and social consequences are identified, minimized, and properly mitigated. The WB carries out screening of each proposed project to determine the appropriate extent and type of EA to be undertaken and whether or not the project may trigger other safeguard policies. The safeguard policies, the triggers for each policy, as well as status of their relevancy for the proposed project are presented in the table below:

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

Environmental Impact Assessment and Environmental Management Plan Reports 16 Construction of multi-profile hospital in Gyumri city, Shirak region

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

Ministry of Nature Protection In general the Ministry of Nature Protection (MNP) is responsible for the protection, sustainable use, and regeneration of natural resources as well as the improvement of the environment in the Republic of Armenia. In those areas, the MNP’s authority includes overseeing national policy development, developing environmental standards and guidelines, and enforcement. The MNP implements these functions through a number of structural departments. With respect to the implementation of the project on construction of a new 200-bed adult multi-profile hospital in Gyumri city the most relevant bodies under MNP includes ƒ State Environmental Expertise SNCO, which conducts environmental assessments, issue conclusions for the activities subject to EIA; and ƒ State Environmental Inspectorate, which through its 11 Regional Environmental Inspectorates oversees the implementation of legislative and regulatory standards in natural resources protection, use and regeneration. It also conducts environmental inspections at worksites for control of environmental measures and valid permits. MNP (in cooperation with MoE) is also responsible for issuing the permits for the opening and operation of new quarries. Information about the functions and spheres of coordination of all the mentioned structural units of the Ministry of Nature Protection can be obtained from the website of the ministry at www.mnp.am.

Ministry of Energy and Natural Resources The Ministry of Energy and Natural Resources (MoE) is a state body of executive authority, which elaborates and implements the policies of the Republic of Armenia Government in the energy and natural resources management sector. With respect to the implementation of the project on construction of a new 200-bed adult multi-profile hospital in Gyumri city the MoE (in cooperation with MNP) is responsible for issuing the permits for the opening and operation of new quarries. Information about the functions and structural units of the Ministry of Energy and Natural Resources can be obtained from the website of the ministry at www.minenergy.am.

Ministry of Culture The Ministry of Culture (MoC) is a state body of executive authority, which is responsible for development and implementation of the RA state policies in the culture sector. The State Agency for the Protection of National Cultural Monuments under the MoC takes the responsibility of the management of the cultural resources and monuments as well as for providing the guidance to the Construction Contractor once any new historical/ cultural/ archaeological monument will be unexpectedly found during civil works.

Information about the functions and structural units of the Ministry of Culture can be obtained from the website of the ministry at www.mincult.am.

Environmental Impact Assessment and Environmental Management Plan Reports 17 Construction of multi-profile hospital in Gyumri city, Shirak region

Ministry of Healthcare The Ministry of Healthcare (MoH) is a state body of executive authority, which elaborates and implements the policies of the Republic of Armenia Government in the healthcare sector. The MoH implements the functions related to development and organization of implementation of healthcare management policy and state projects, development and approval and sanitary norms and rules, drafting as well as oversight over implementation of laws and regulations related to healthcare sector. The MoH has the following separate divisions and state agencies: • National Healthcare Agency ((includes 11 regional branches); • National Hygiene and Anti-Epidemiological Surveillance Inspectorate (operates through number of branches established in Yerevan and regional centers)

Information about the functions and structural units of the Ministry of Health can be obtained from the website of the ministry at www.moh.am.

Health Project Implementation Unit (HPIU) is the coordination unit for the on-going Armenia Health System Modernization Project. The HPIU will be responsible for the fiduciary aspects of the project and provide project administration and coordination support to the MoH line departments and agencies that are responsible for the implementation of project components. With respect to the implementation of the project on construction of a new hospital in Gyumri city HPIU will provide overall supervision of works, including their environmental compliance to local legislation and WB relevant policies, and ensure quality of work implemented by the Supervision Contractor (to be hired by HPIU). The Supervision Contractor and the Construction Supervision Unit headed by the Civil Works and Environmental Specialist of HPIU will be responsible for implementing the supervision over construction activities. The architectural design contractor hired by HPIU carries out authorship supervision during the construction process will supervise timely, proper and reliable implementation of the construction works on a daily basis. Along with other responsibilities the Supervision Contractor will be assigned to track compliance by the civil works contractors with the EMP. HPIU appropriate specialist shall conduct periodical visits to construction sites to ensure proper implementation of EMP. HPIU specialist will also coordinate environmental training for staff, designers and local contractors to ensure proper understanding if environmental requirements. HPIU will prepare reports outlining status of EMP implementation as part of the regular progress reporting.

To coordinate and supervise the project, the MoH established a Coordination Board consisting of representatives of the key stakeholders within and external to the Ministry for the purposes of guiding and coordinating the policy of optimizing the health sector. In addition to the general discussion of policy, the Board (or by decision of the Board, certain members) will be involved in such issues as defining terms of references, participating in technical evaluations, and working directly with consultants for the strategic technical assistance assignments.

The World Bank will supervise environmental compliance of the Project by reviewing regular progress reports and by taking periodical supervision missions implying site visits, random checks of Project documents on file, and verification of the consistency of reports/documents with a factual situation on the ground. Status of the project’s environmental performance will be reflected in the World Bank’s supervision reports, including Mid-Term Review and the Implementation Completion and Results report. Coordination Board established by MoH, consisting of representatives of the key stakeholders, will coordinate and supervise the overall project implementation.

Environmental Impact Assessment and Environmental Management Plan Reports 18 Construction of multi-profile hospital in Gyumri city, Shirak region

4. Project Description Based on the study of current capacities, building conditions, state of equipment, as well as utilization indicators of health care services one can conclude that the most optimal model of hospital care organization in Gyumri city of Shirak region is consolidation of all services in one well-equipped multi-profile hospital with modern building conditions. Studies of international experts of the previous years have also shown that this option will assure high quality and maximal efficiency of hospital services in Gyumri. Therefore the Government decree #1911-N on optimization of regional health care systems stipulates the merger of adult therapeutic and surgical services of Shirak regional hospital, Samariter and Gyulbenkyan surgical hospitals in one new “Gyumri Medical Center” around 200 bed capacity (including intensive care). Taking into consideration that none of the existing hospitals of Gyumri has an infrastructure appropriate for delivery of quality hospital care the decision was taken to construct a new building next to the Austrian children’s hospital to room the services of “Gyumri Medical Center”.

Satellite photo of the project area showing location of the new hospital is presented below:

Source of the satellite photo: http://wikimapir.org (Accessed on November 2009)

As a result the buildings of Shirak region Hospital, Gyumri Samariter and Gyulbenkyan Hospitals (~ 16.000 square meters in total) would be vacated and turned on to Shirak regional government leading to reduced maintenance and administrative costs and more funds toward extension of BBP services, therefore increased accessibility of medical services for population, especially for social vulnerable groups.

The new medical center will be constructed at the expense of the Credit Funds of the World Bank supported Armenia Health System Modernization Project. The building will be consisted of one block with a boiler house and electrical sub-station. The latter will also serve the needs of the neighboring Austrian children’s hospital.

The total are of the site allocated for construction comprises 0.604140 ha; the site is located on address N 3/3 Garegin Nzhdeh str. in Gyumri. Site plan of the new hospital is presented below:

Environmental Impact Assessment and Environmental Management Plan Reports 19 Construction of multi-profile hospital in Gyumri city, Shirak region

Site Plan of the hospital

Environmental Impact Assessment and Environmental Management Plan Reports 20 Construction of multi-profile hospital in Gyumri city, Shirak region

According to initial estimation 388 members of personnel are needed as full-term employees, including 128 physicians and 260 nurses, meaning that the described optimization program will not lead to reduction of the present medical personnel (physicians and nurses) of Gyumri hospitals.

The departments and bed capacity of the current three Gyumri hospitals and the new “Gyumri Medical Center” is presented in the below table.

Present Bed Bed Space Utility Future Departments Bed hospitals fund occupancy in m2 expenses hospital fund in AMD Shirak 60 53% 8447 14000,0 Adult therapeutics, 100 regional (mainly at the New incl. Cardiology hospital cardiology) Gyumri and neurology Medical Gyulbenkyan 100 45% 3790 12475,7 Centre Adult surgery, incl. 100 Surgical (mainly general surgery Hospital trauma) (urology, ENT, vascular, eye, Samariter 70 60% 3332 9940,7 neurosurgery) and 10 Hospital trauma/orthopaedics (ICU)

Total 230 45% 15569 57208,1 210

Admissions of the Medical Center with emergency services, diagnostic-out-patient department, as well as the hospital administration will be located on the first floor of the new building. The therapeutic department including neurology services, cardiology department, ICU and CCU units and a day surgery unit will be located on the second floor, while the third floor will be entirely occupied by adult’s trauma and surgical departments, including urology, ENT, cardiology, ophthalmology and neurosurgery services with 3 operating theatres.

The Armenia Health System Modernization Project will also provide funds for basic medical equipment and furniture of the Center contributing to improved quality of provided services. Technical assistance for the improvement of management systems with introduction of new management functions, such as for in-hospital quality management and health care waste management are as well planned to be implemented in the scope of the project.

Design for the new “Gyumri Medical Center” is developed in accordance with RA construction norms 1-3.01-07. Proposed building will consist of four-floor structure with basement and tile roofing. The area of each flow is presented below:

Basement 1307.3 m2; I floor 2853.9 m2; II floor 2481.1 m2; III floor 2495.6 m2; Mansard 2322.7 m2.

Environmental Impact Assessment and Environmental Management Plan Reports 21 Construction of multi-profile hospital in Gyumri city, Shirak region

To ensure adequate conditions for workers as well as proposed implementation of construction activities establishment of the following temporary structures is proposed by design:

ƒ one repair-mechanical workshop with size 7.5x3.1x3.1m; ƒ one construction laboratory with size 6x3x3m; ƒ one office with size 9x2.7x2.7m, ƒ two locker-rooms with rest area and heating (for 14 person), size 6.7x3x3m; ƒ shower (for 6 person) with size 9x3.1x2.8m; ƒ two toilets (for 4 person) with size 8x3.5x 3.1m.

Medical aid station and cafeteria of the Austrian children’s hospital will be used to provide respective services during the construction. Since implementation of construction works requires production of large volume of concrete, it is envisaged to install on-site concrete- mixing plant and with appropriate storage for sand and gravel.

It is planned to arrange green spaces with total area of 3000 m2.

General parameters of construction works: According to the schedule total duration of construction works comprises 21 months, out of which duration of earth and restoration works is 4 months. Implementation of concrete works will take 8 months.

The following construction machinery and equipments is envisaged to be involved ion implementation of works:

ƒ excavator, 2 units, 60l; ƒ dump truck, 4 units, 80l; ƒ concrete mixer, 2 units, 60l; ƒ lift-truck, 1 unit, 10l; ƒ asphalt-placing machine, 1 unit, 50l.

Total volume of earth will comprise 10516 m3/constr.period. Backfilled earth volume is 2604m3.

Land use and circulation plan of the hospital is presented in a scheme below:

Environmental Impact Assessment and Environmental Management Plan Reports 22 Construction of multi-profile hospital in Gyumri city, Shirak region

Land use and circulation plan of the hospital

Environmental Impact Assessment and Environmental Management Plan Reports 23 Construction of multi-profile hospital in Gyumri city, Shirak region

5. Description of the Project Environment General information The proposed project area is located in the northwestern part of the country in the region of Shirak. In the west Shirak region borders with Turkey, in the north it borders with Georgia, in the east – Lori region and in the south – Aragatsotn region of Armenia. The map and basic data on the region are presented below:

Name of the region: Shirak

Territory: 2643 km2

Population: 257 242 (de facto as of 2001 census)

Region centre: Gyumri

No of urban settlements: 3

No of rural settlements: 128

Source of the Map: www.armeniainfo.am (Accessed on September 2009)

Geographical location and climate Southern part of the Shirak region is lying in predominantly semi-desert to desert mountain steppe terrain, while the northern area rises over alpine meadows. The Region is bordered by Mt. Aragats on the southeast, the Bazruma and Javakh Mountain ranges on the east. The Akhuryan River begins in Shirak region, runs just west of Gyumri before forming the border between Turkey and Armenia at Akhurik.

Half of the region lies on the Kars and Shirak Plateaus, a complex mountain steppe region that includes swamp and marshland, large tracts of semi-desert, mountain steppe and mountain/alpine meadows with pockets of forests nestled inside mountain clefts. The Southern area relies mainly on irrigation and springs to cultivate agriculture.

Being at the height of 1500-2000 m above sea level (52 villages of the region are at the height of 1500-1700 m above sea level and 55 villages - 2000 m), the region is the coldest region of Armenia, where the air temperature sometimes reaches -460C in winter. Summer

Environmental Impact Assessment and Environmental Management Plan Reports 24 Construction of multi-profile hospital in Gyumri city, Shirak region is hot and dry. Annual precipitation is 500mm in the Shirak plateau and up to 900mm on the Aragats slopes.

In terms of climatic conditions the plot is located in II–B sub-region. The summer here is moderately hot, the average temperature in July is +19C and the absolute maximum is +38C. The average temperature in winter in January is -10.5C and the absolute minimum is -36C. Annual average amount of precipitation is 509mm. Thickness of snow cover comprises 24cm, and pressure – 70kg/m2. North-eastern (in July) and northern (in January) wind directions predominate with wind speed up to 4.2m/sec. Depth of soil freezing is 143cm.

Values of key climatic and meteorological parameters are summarized in the table below:

Name of parameter Value Coefficient of atmospheric stratification, A 200 Coefficient of the area relief 1.0 Maximal outside temperature of the most hot month of the year, 0C + 23,9 Average outside temperature of the most hot month of the year, 0C + 19.3 Average outside temperature of the most cold month of the year, 0C - 9.7 Maximal absolute air temperature, 0C + 38 Minimal absolute air temperature, 0C - 36 Annual precipitation, mm 509 Repetition of wind directions (wind rose), % Northern 19 North-eastern 40 Eastern 13 South-eastern 2 Southern 5 South-western 8 Western 6 North-western 7 Calm 52 Ux, m/sec 7

In terms of geomorphology the mentioned area is located within the bounds of Shirak valley, which is a broad depression framed as a result of contemporary tectonic movements and where intensive accumulation of lacustrine sediments, alluvial, deluvial, proluvial and volcanic substance took place. In terms of hydrogeology the underground water of the mentioned area mainly relates to alluvial, deluvial, proluvial and lacustrine- river sediments of forth generation, which are prevalent in this area.

According to seismic zoning map Gyumri city is located in III seismic zone.

Environmental Impact Assessment and Environmental Management Plan Reports 25 Construction of multi-profile hospital in Gyumri city, Shirak region

The plot area of the designed construction has quite plane relief 1558,0 - 1559,5 meters in absolute marks (engineering-geological survey of the land-plot of hospital extension with written conclusion on the state of soil is performed in the scope of architectural design works of hospital construction).

The proposed location of a new hospital is located in the north-eastern part of the Gyumri city, nearby the Garegin Nzhdeh and Chaykovsky streets crossing. The total area of the land plot is 0.604140 ha. The plot is fully covered by construction waste and ruins of old buildings. From south and west the plot is neighboring the Austrian children’s hospital. On the north site the new hospital is adjacent to Chaykovsky str. on both sides of which 7-8 small wagons in very poor state are located. Wagons appear here as a temporary living facilities after a devastating earthquake of 1988. Most of the wagons are abandoned, since the inhabitants were provided with an apartment, however a couple of them are still used, while the new residential houses are constructed by Government. The wagons are located at a distance of 80-100m from the proposed construction site.

Hydrology The major river of Shirak is Akhuryan, which starts from Lake Arpi and is the first tributary of the Araks river. The river starts at 2017m elevation and has the length of 186km. In its middle and lower parts the river marks the border between Armenia and Turkey, and flows into the river Araks on 708th km from its estuary. Watershed on the Akhuryan river is 9700km2 out of which 2784 km2 is located in the territory of Republic. The Akhuryan river is the only water source for the western part of the country and its water is widely used for irrigation and industrial purposes. The water of the river is taken for irrigation through a number of canals. Lake Arpi was turned into a water reservoir is located in the upper flow of the river, while in its middle flow the biggest reservoir in Armenia – Akhuryan reservoir (525 Mm3) – is constructed. A number of smaller reservoirs are also fed by Akhuryan river.

Lake Arpi, situated in the northwest corner of Shirak, is one of the world’s most ecologically important lakes, supporting several unique and endangered species of wildlife. Arpa, with its 20 square kilometer surface area and maximum depth of only 8 meters, is fed by the Yeghnajur, Karmrajur and Elal Rivers. In turn, it is the source of the Akhuryan River.

Main tributaries of Akhuryan are Gyumriget, Jajurget and Karkachun, which dry out during the summer season.

Typical characteristics of the flow of the river Akhuryan at the hydrological stations located along the river are presented in the below table.

Catchment Annual flow, Mm3 River – Hydrological Station 2 area, km Average year 25% probability 75% probability Akhuryan – v. Paghakn 220 62.5 73.8 46.7 Akhuryan – v. Akhurik 1060 307.7 340.8 259.7 Akhuryan – v. Haykadzor 8140 1085.6 1164.5 798.4

The following quantitative parameters, such as water level, discharge, ice phenomena along with the temperature, turbidity and suspended solids are measured two times a day (at 8AM and 8PM) in the hydrological stations (water quantity monitoring stations). The

Environmental Impact Assessment and Environmental Management Plan Reports 26 Construction of multi-profile hospital in Gyumri city, Shirak region data of such measurements and observations is available in the Reference on State of Surface Water for 2008, developed by the EIMC of RA MNP obtained through www.meteo.am.

Source of the Map: Reference on State of Surface Water for 2008, developed by the EIMC of RA MNP www.mnp.am (Accessed on November 2009)

There are two operating water quality monitoring stations located nearby Gyumri city: first station is located 5km upstream Gyumri city, and the second is located 5km downstream Gyumri city. In these water quality monitoring stations the following parameters are measured: temperature, transparency, mineralization, COD5, suspended solids, colority, odour, dissolved oxygen, pH, hardness, hydro carbonates, carbonates, sulphates, chlorides, nitrates, nitrites, ammonia, oil products, Ca, Mg, Na, K, Al, Cr, Fe, Mn, Co, Ni, Cu, Zn, As, Mo, Ag, Cd, Pb, Sn, Sb, etc. The data on water quality measured in the station located in the basin of the river Akhuryan is available through www.mnp.am.

According to the data provided in the annual report of Environmental Impact Monitoring Center of the Ministry of Nature Protection for 2008 some exceedence of aluminium, vanadium, manganese and copper was observed in the samples taken from river Akhuryan nearby Gyumri city (see the table below). The other parameters were within allowed limits.

Location of the water Number of Number of cases Exceedence of average Parameters quality monitoring samples of MAC concentrations over exceeding MAC station taken exceedence MAC (multiplier)

5km 7 BOD5 4 1,2 upstream Aluminium 7 42,2 Gyumri Vanadium 7 16,0 Chromium 5 3,0 Iron 6 4,6

Environmental Impact Assessment and Environmental Management Plan Reports 27 Construction of multi-profile hospital in Gyumri city, Shirak region

Location of the water Number of Number of cases Exceedence of average Parameters quality monitoring samples of MAC concentrations over exceeding MAC station taken exceedence MAC (multiplier)

Manganese 7 7,6 Copper 7 5,0 Nitrite ion 6 4,8 Ammonia ion 5 4,5

BOD5 5 1,3 5km Aluminium 7 23,5 downstream 7 Vanadium 7 12,0 Gyumri Chromium 4 2,0 Iron 5 2,6 Manganese 7 7,9 Copper 7 4,0

The water of Akhuryan river, is mostly used for irrigation purposes as the rural population of the region is extensively involved in agricultural activities, and particularly in gardening, farming and cattle breeding. Urban population is involved in light and food industry. Water of the river Akhuryan is also used for industrial purposes by a number of enterprises operating in Gyumri, Artik and Akhuryan, which are considered as potential polluters of the river water.

Underground water resources are located in depth of 5.4 – 6.2m, however depending on annual fluctuation the water table can raise up to 0.5 – 0.8m. The underground water resources belong to non-pressure aquifer. According to laboratory analysis water is not aggressive towards concrete.

There are no water bodies located nearby the land plot allocated for construction of a new hospital.

The building of a new hospital in Gyumri will be connected to the city water supply system. The water measurement device with diameter equal to 50mm, will be installed at the pumping station of the hospital. It is envisaged to install two steel water supply pipelines with diameter of 76x3.0mm covered with anti-corrosive insulation. The pipes with diameter of 32mm will be made of steel, and the pipes with smaller diameter will be metal-plastic. Internal water system is circulatory. Hot water will be supplied from boiler house to be constructed as a part of the proposed project. It is also envisaged to construct four polyethylene small reservoirs (each with a volume of 5.0 cubic meters) in a hospital basement to ensure uninterrupted water supply and to support hospital operation during water supply cut-offs through city network.

Wastewater system a new hospital in Gyumri will be pumped to the sewerage collector of the city network located nearby Nzhdeh Street. Wastewater discharge pressure pipeline is made of polyethylene, where installation of cleaners is envisaged each 35 meters. Internal sewerage network will be made of polyethylene pipes with diameter of 100 and 500 mm, while the diameter of external pipelines will be 200mm. Sewerage wells will be made of round-shape reinforced concrete prefabricated elements.

Environmental Impact Assessment and Environmental Management Plan Reports 28 Construction of multi-profile hospital in Gyumri city, Shirak region

Flora Shirak lies in stark contrast to the rest of the country, with its southern area lying in predominantly semi-desert to desert mountain steppe terrain, while the northern area rises over alpine meadows called Armenia’s "Siberia". Natural landscapes of Shirak are not homogenious. There are no natural forests located in the region.

Northern Shirak flora include Iris lineolata, I. Caucasica, Merendera mirzoeval, Colchicum Szoritsii, Gagea ssp., Puschkinia scilloides, Draba ssp., Lallemautia caneseeus, Ranunculus ssp.,Myosotis alpestris, Pedicularis ssp., Trifolium ssp.,

Lower Elevation sagebrush steppe flora includes Gladiolus atroviolaceus, Nigella oxypetala, Actynolema macrolema, Gundelia tournefort, Verbascum saccatum, Lallemanita iberica, Roemeria retracta, Scabiosa argentea, Scorronera paposa, Muscari beglecta, Stchys inflata, Astragalus distyophysus, A. kochianus, Achillea tenuifolia, Helichrysum rubicundum, Silena spergulifolia.

River gorge include flora include Alkanna orientalis, Cerasus incana, Prus, salicifolia, Cerasus mahaleb, Amygdalus ferzlinia, Spirala crenata, Saxifraga cymbalaria.

Desert and semi-desert flora include sagebrush, steppe grass, straw flowers, poppies and daisies.

The project area is mainly covered with the steppe zone cereal and grass crops are spread, in particular including the Festuca valesiaca Gaudin, F. ovina L., Koeleria albovii Domin, K. cristata (L.) Pers., Bothriochloa ischaemum (I.) Keng, Stipa capillata L., S. Lessingiana Trin.et Rupr., S. tirsa Stev., Elytrigia trichophora (Link) Nevski, Galium verum L., Agropyron, Andropogon, Scabiosa, Veronica, Artemisia, Achillea, Astragalus, and Datura stramonium.

Red book and rare species include sambukus tigranii.

Land plot allocated for construction of a hew hospital does not contain any forested area or rare/endangered species mentioned above.

Fauna The rock formations and scrub land vegetation that makeup the bulk of southern Shirak are unique ecosystems, filled with desert wildlife, and the bulk of migrating steppe birds in the spring and fall.

Between Gyumri and the Georgian border, the land slowly rises to the foot of the Javakh Range. The area is notorious for being the coldest area in Armenia throughout the year, though it is a rich marshland with scattered swamps that supports waterfowl and possibly the highest altitude habitat for the stork and crane.

Fauna of Shirak is presented by Caucasus and Asia Minor fauna types. The largest prairie dog population in Armenia is in Shirak, located west of Maralik. Nutria, moles, jackal and wildcats are frequently seen in the region as well. The most spread varieties include partridge, lake frog, lizard, anguine lizard, sparrow, hooded crow, magpie, vole, grey rat, wolf and fox. Invertebrates include earthworm, crawfish, ant, bee, cricket, grasshopper, plant louse, cabbage white butterfly, mosquito, fly, etc.

Land plot allocated for construction of a hew hospital does not contain representatives of unique ecosystems and does not serve as a habitat for animal species mentioned above. Environmental Impact Assessment and Environmental Management Plan Reports 29 Construction of multi-profile hospital in Gyumri city, Shirak region

Specially Protected Areas

There are no specially protected areas located nearby or in close distance to Gyumri.

However there are two protected areas established in Shirak region in order to ensure protection, natural development, reproduction, sustainable use of the flora and fauna species:

Aragats Alpian Protected Area – established in 1959 on 300 ha area, and located in the border of Shirak and Aragatsotn regions;

Lake Arpi National Park – established in 2009, on the north-western part of the Shirak region. Lake Apri National Park was established jointly with WWF with an aim to conserve the unique biodiversity of the Javakheti-Shirak plateau in Armenia. The Javakheti-Shirak plateau in Armenia is part of a large high mountain plateau of volcanic origin with mountain steppes, sub-alpine grasslands as well as lakes and wetlands.

Social information According to the results of 2001 Census of the Republic of Armenia the population of Shirak region in total was 257 242 (de facto), out of which the male population comprised 118 021 (45.8%) and female population – 139 221 (54.2%). The territory of region is 2643km2 and the population density is 97.33 (person/km2). There are 161 298 urban inhabitants residing in the 3 cities of the region and 95 944 rural inhabitants living in 128 rural communities.

The urban settlements are Gyumri, Artik and Maralik. Gyumri is the capital of the region and is the second biggest city in the republic and biggest in the Shirak region. Artik is the second, and Maralik is the third largest city of the region. In total there are 128 rural settlements located in the region.

Basic social information with respect to Gyumri city where the project area is located is presented below.

Gyumri city Gyumri is the Shirak regional center and the second biggest city after the capital Yerevan of Armenia. Gyumri city is located at a distance of 120 km from capital Yerevan at elevation 1550m above sea level. City is located on the left bank of river Akhuryan. According to the results of 2001 Census of the Republic of Armenia the population comprised 140 318 (de facto), out of which the male population comprised 64 221 (45.7%) and female population – 76 097 (54.3%). In the result of the devastating earthquake of 1988 most of the city infrastructure was destroyed, including residential, service and well-developed industrial infrastructure. City rehabilitation and reconstruction process still ongoing. Currently there are 57 secondary, 9 musical and art, 31 sport schools, 30 pre-schools, 2 institutes, 15 libraries, 5 hotels, 3 museums, dramatic theatre, etc. Four TV and radio broadcasting companies operates in Gyumri and provide coverage for the whole territory of region.

Economics and Mineral Resources The bulk of Armenia's marble, limestone, perlite, pumice and tuf are mined in Shirak region, as well as granite. Minerals found in Shirak include mercury, barium, copper, tin, silver and coal. Gems include amethyst, obsidian, quartz, carnelian, garnet, beryl, turquoise, aquamarine, lapis lazuli and diamonds.

Environmental Impact Assessment and Environmental Management Plan Reports 30 Construction of multi-profile hospital in Gyumri city, Shirak region

Historical and Cultural Monuments Shirak region is home to many historical and cultural monuments. The most famous are the architectural splendor of Haritch, Marmashen and many other churches and monasteries

The famous pagan monument, Tsak Kar (literally hole stone) is situated in Toparli, an idyllic mountain village. The monument is a huge stone with a hole just big enough for a person to squeeze through.

Haritch Monastery (7th to 13th cc.) was built with giant multicolored stones-each 3.5 meters wide. It is adjacent to the 7th Century St. Grigor Church. For centuries, Haritch was the summer residence of Armenian Catholicos.

There are no historical and cultural monuments located nearby the hospital to be constructed. No archaeological or cultural resources are expected to be encountered during project implementation since major construction works will be implemented in the area where excavations have been conducted before and no findings have been reported.

Environmental Impact Assessment and Environmental Management Plan Reports 31 Construction of multi-profile hospital in Gyumri city, Shirak region

6. Project Alternatives

An alternative to the current project would be rehabilitation of the current Shirak regional hospital or Gyulbenkyan Surgical Hospital with concentration of all adult surgical services on that site and concentration of all adult therapeutic services in the current Samariter hospital of Gyumri city. This alternative however would result in split of adult surgery and therapeutic services into two sites. Moreover, further studies of the Gyumri hospital buildings showed that Gyulbenkyan Surgical Hospital as a non-typical hospital building allocated for hospital use after the devastating earthquake of 1988 and Shirak regional hospital most part of which was constructed in 1937 required significant investments for rehabilitation and even then would not be totally appropriate for provision of quality hospital services.

Another alternative considered is a “No Action” alternative, which addresses the situation with no Project implemented i.e. the construction of 200-bed multi-profile hospital in Gyumri city is not carried out. In general “No Action” alternative is applied in respect to the Project as a whole. In this case “No Action” alternative will lead to the following consequences:

• Insufficient provision of health care services on the basis of family medicine, • Further deterioration of hospital networks in the regions, • Distribution of healthcare services in different medical centers, which reduces the efficiency and reliability of diagnostics and treatment; • Reduction of access to quality health care services provided to the population, in particular the most vulnerable groups, and • Increase of O&M costs associated with healthcare infrastructure; • Increased migration from rural areas, and • Decline of socio-economic situation and in population welfare.

Based on above list it may be stated that the potential negative consequences of the “No Action” alternative greatly overweight the environmental risks associated with the Project implementation.

7. Potential Impacts and Mitigation Measures This section addresses major potential environmental impacts associated with the construction and operation of a new hospital in Gyumri, and presents proposed mitigation measures.

The project is not expected to have significant or irreversible negative environmental impacts neither at the construction, nor at operation phases. Impacts of the construction phase will be typical for all medium scale construction activities, short-term and limited to the project sites which are State owned land plots with user rights already granted to the medical institutions currently operating in these plots. Impacts of the operation phase will be typical for operating medical institutions. There are no specially protected areas or threatened or endangered endemic species in the project area.

Environmental Impact Assessment and Environmental Management Plan Reports 32 Construction of multi-profile hospital in Gyumri city, Shirak region

The likely adverse environmental impacts during the construction phase will include the following: degradation of soil, landscape and soil erosion due to improper disposal of excavated materials and construction waste; spillage of oil and other substances during the construction; pollution of water resources and soil by construction run-offs; use of temporary construction sites (access roads, camps, machinery sites, storage facilities, etc); use of borrow pits; extraction of aggregate material, such as gravel, sand, rock; temporary air pollution related to increased truck traffic during the construction, release of dust from digging-loading works and heavy machinery operation; noise and vibration disturbances; safety hazards during implementation of construction works. The likely adverse environmental impacts during the operation phase include the following: emissions to atmosphere associated with operation of heating system and subsequent emission of pollutants originated during burning of fuel; impacts on water and soil as a result of improper maintenance of water supply and wastewater system, drainage system, vehicles and equipment, boiler house and electrical sub-station, safety hazards associated with improper operation or absence of fire-fighting system; waste disposal issues associated with improper categorization and utilization/disposal of domestic and medical waste generated in the hospital. The long-term positive socio-economic impacts of the operation of a new 200-bed adult multi-profile hospital in Gyumri city, on the other hand, are expected to be significant, since the Project will provide reliable primary health care services on the basis of family medicine, upgraded hospital networks in the regions, improved access to quality health care services provided to the population, in particular the most vulnerable groups, reduction of O&M costs; creation of new employment opportunities; overall improvement of the socio-economic situation and population welfare.

The most important potential short-term and long-term environmental and social impacts as well as relevant mitigation measures are presented below.

7.1 Expected Short Term Environmental and Social Impacts

The potential negative environmental and social impacts of the Project implementation – construction of a new 200-bed adult multi-profile hospital in Gyumri city, Shirak region – in the sort-term run are of modest nature and are presented below.

The potential negative environmental and social impacts expected during construction works are followings: • Generation of excavated materials and construction wastes. Excavated earth and construction wastes will be generated during earth works on foundations and the construction works of new hospital building and associated infrastructure (including boiler house and electrical sub-station). These effects will be localized, and will be minimized by means of appropriate removal and disposal procedures; • Degradation of landscapes and soil erosion. Implementation of earthworks associated with construction works of new hospital and associated infrastructure may cause degradation of existing landscape and soil erosion. These impacts will be mostly associated with installation of on-site concrete-mixing plant, construction material storage and waste temporary accumulation site; • Impacts from temporary access roads and work sites. Installation of on-site concrete-mixing plant, as well as construction materials storage and waste temporary accumulation site, camp, machinery site, storage facilities can enhance soil erosion, and degrade the landscape;

Environmental Impact Assessment and Environmental Management Plan Reports 33 Construction of multi-profile hospital in Gyumri city, Shirak region

• Pollution of water and soil by construction run-offs. Improper storage of construction materials, construction waste and excavated materials, as well as spillage of fuel, oil and other substances during construction can cause pollution of soil and/or water. It should me mentioned that there are no water bodies located nearby the proposed construction site; • Noise and vibration disturbances during construction are related to the implementation of civil works and truck traffic associated with transportation of construction materials/waste. These impacts will occur during the construction works and will include noise and vibration caused by operation of heavy machinery; • Temporary air pollution (dust) occur during construction works and includes release of dust from digging-loading works and heavy machinery operation, emission of harmful substances from combustion of diesel used by transportation means and machinery during the construction works, emissions from welding, concrete-mixing, asphalt-placing, activities, as well as dust caused by improper storage of friable construction materials and non-timely disposal of friable construction waste. According to calculations provided further in this chapter level of emission is expected to be within the appropriate RA standards/norms. • Safety hazards from construction activities include injuries of workers who were not applying appropriate Personal protective equipment (such as gloves, hard hats, safety glasses, ear plugs, aprons, safety shoes, and respirators). Prevention of injuries and accidents is an important factor to be considered during construction works, since a single injury can handicap an employee for life, or it can be fatal. No major hazards are expected during the construction activities, as long as proper safety procedures (including appropriate safety uniform and equipment) are applied; • Threats of extracting aggregate materials (such as gravel, sand, rock, etc) include uncontrolled extraction of rock and harvest of sand and gravel from the riverbeds. The uncontrolled extraction of materials by quarry activities may cause landscape degradation, irreversible loss of soils, while excessive harvest of sand and gravel may impact the stream morphology, bed load movement, water quality, habitat quality and quantity. In Armenia Construction Contractor can choose the quarry/borrow pit sites to be used for material extraction; some of them even possess their own quarries approved by the respective state entities. No major threats are expected as long as the Contractor uses the approved quarries/borrow pits for material extraction and properly restore them after the completion of works. • Disturbance to nearby located residents and businesses is associated with temporary air pollution, noise and vibration caused during implementation of civil works and operation of heavy machinery.

Description of potential impacts on the environment during the construction phase of the project is presented below.

Air quality: Emission of dust from digging-loading works, harmful substances from combustion of diesel used by transportation means and machinery during the construction works, welding and concrete mixing, asphalt placing works were calculated based on the operating standard. These pollutants contribute to greenhouses gases and may cause direct and indirect health problems of the people working and living in the area (such as respiratory diseases, allergies, etc.).The summarized results are presented in the table below.

Environmental Impact Assessment and Environmental Management Plan Reports 34 Construction of multi-profile hospital in Gyumri city, Shirak region

Emission of harmful substances during the construction works

Amount of harmful substances emitted into atmosphere, t/year, g/sec Construction works Inorganic Cement Welding Mn CO VOS* NOx SO SP** dust dust 2 aerosol oxides Digging-loading 1.45 ------works (5.01) Machinery 0.17 ------operation (0.45) Emissions 0.66 0.064 0.321 0.046 0.032 associated with - - - - (2.27) (0.225) (1.1) (0.16) (0.11) diesel fuel 0.016 0.002 Welding works ------(0.124) (0.016) 0.028 Concrete works ------(0.144) Preparation of - 2.2 (7.6) ------concrete mix Asphalt-placing 0.66 ------works (3.44) 1.62 0.66 0.752 0.321 0.046 0.032 0.016 0.002 TOTAL 2.2 (7.6) (5.46) (2.27) (3.81) (1.1) (0.16) (0.11) (0.124) (0.016) * Volatile organic substances ** Solid particles

Near-earth concentrations of atmospheric emissions: Near-earth concentration of emissions was calculated by using “Raduga”1/ “Rainbow” computer software. Input data and assumptions used, as well as analysis data are presented in the design technical documentation. The results are presented in the table below. Calculation of near-earth concentrations of emissions

Absolute value of maximal Maximal pollution by N: Pollutant pollution, mg/m3 MAC parts 1 Inorganic dust 0.0006 0.0011 2 Carbon oxide 0.00017 0.000034 3 Hydrocarbons 0.0002 0.0002 4 Nitrogen dioxide 0.000085 0.001 5 Sulphur dioxide 0.000012 0.000024 6 Suspended solids 0.000011 0.000074 7 Welding aerosol 0.000005 0.00001 8 Manganese oxide - 0.00005 9 Cement dust 0.047 0.155

During the construction phase the emissions will have temporary nature and as a result of dispersion with atmospheric air the near-earth concentration of substances will not exceed the MACs for inhabited areas.

Environmental Impact Assessment and Environmental Management Plan Reports 35 Construction of multi-profile hospital in Gyumri city, Shirak region

Water use and wastewater: During construction works water is used for concrete preparation, watering the construction sites, as well as for ensuring proper conditions for workers and drivers. Taking into account that construction activities will be implemented on one working site with calculated area equal to 2854 m2, watering calculation were conducted for the area mentioned only. In total water consumption for construction phase will comprise 18.25 m3/ day.

Water used for concrete preparation and watering the construction site is considered as non-return water se. Wastewater originated as a result of drinking water consumption is estimated at 1.18 m3/day.

Soils: The top soil is to be stripped and stored for rehabilitation of the construction site after the completion of the construction works. Implementation of the proposed project will be associated with the excavation of 10516m3, out of which 8938.6m3 will be used for backfilling. Remaining amount of excessive soil will be used for restoration of other sites. Construction waste originated during the works will be transported and disposed at specially agreed dump site, agreed with Gyumri city hall.

7.2 Expected Long Term Social and Environmental Impacts

Construction of a new 200-bed adult multi-profile hospital in Gyumri city, Shirak region will bring positive changes to provision of reliable, high-quality and timely healthcare services. The expected overall social and environmental impacts from the construction of the new hospital will be positive, long–term and cumulative in nature, ultimately contributing to the increased social and economic benefits of the population of Gyumri and Shirak region.

The long-term environmental impacts expected during hospital operation are followings:

• Emissions to atmosphere associated with operation of heating system and subsequent emission of pollutants originated during burning of fuel. According to calculations provided further in this chapter level of emission is expected to be within the appropriate RA standards/norms; • Impacts on water and soil as a result of improper maintenance of water supply and wastewater system, drainage system, vehicles and equipment, boiler house and electrical sub-station, domestic and medical waste disposal; • Safety hazards during hospital operation are associated with improper operation or absence of fire-fighting system; • Waste disposal issues are associated with improper categorization and utilization/disposal of domestic and medical waste generated in the hospital.

Description of potential impacts on the environment during the hospital operation phase is presented below.

Impact on atmosphere is associated with operation of heating system and subsequent emission of pollutants originated during burning of fuel. According to design separate boiler house will be constructed to provide hospital with heating, air conditioning and hot water supply. Boiler house will operate by means of natural gas, however there will be reserve boiler which will work with diesel fuel. The maximum heat demand of the hospital Environmental Impact Assessment and Environmental Management Plan Reports 36 Construction of multi-profile hospital in Gyumri city, Shirak region comprises 1385 KWt or 1191580 kcal/hour. The total design capacity of the boiler house comprise 735 x 2 + 310 = 1780 KWt or 1530800 kcal/hour. In winter time the capacity will be equal to1470 KWt. Calculations near-earth concentration of emissions of pollutants to be released during boiler house operation both by means of natural gas and diesel fuel shows that all possible emissions are within MACs.

Water supply network of newly constructed hospital will be connected to Gyumri city water supply system. To ensure fire-fighting safety, it is envisaged to arrange a hydrant. Total volume of water to be consumed by hospital is estimated to be 23533.7m3/year.

Hospital wastewater system will be discharged into the well constructed in the yard, and then through submerged pump will be pumped into sewerage collector laid under the Garegin Nzhdeh street. Total volume of water to be discharged into sewerage network is estimated to be 18262.42 m3/year.

The waste generated in the hospital will be categorized as follows for management purposes: o Clinical waste, consisted of bio-hazardous waste including sanitary dressings, human tissue, specimens, infectious materials (items in contact with infectious patients, infected linen etc), sharps including hypodermic needles and syringes, scalpel blades, razor blades etc), pathological/anatomical waste, chemical and pharmaceutical waste. o Domestic waste, consisted of organic domestic waste (food wastage, garden wastage etc); non-organic domestic waste (plastics, non aluminum cans, cardboard packaging etc); and domestic recyclable waste (bottles, newspapers, aluminum cans etc).

The main long-term social impacts of the Project are followings:

• Reliable, high-quality and timely provision of primary health care services on the basis of family medicine; • Upgraded hospital facility with up-to-date equipment; • Concentration of healthcare services in one medical center, which will increase the efficiency of services provided to population and will reduce dependence on visiting different medical departments located in various places; • Considerable reduction of O&M costs associated with healthcare infrastructure; • Improved access to quality health care services provided to the population, and in particular to the most vulnerable groups; • Establishment of new opportunities for retraining of family doctors and nurses; • Creation of new employment opportunities (including temporary employment during construction phase); • Reduction of migration from rural areas, and • Overall improvement of the socio-economic situation and population welfare.

7.3 Mitigation Measures

Environmental Impact Assessment and Environmental Management Plan Reports 37 Construction of multi-profile hospital in Gyumri city, Shirak region

The key measures recommended to mitigate the above mentioned adverse impacts for hospital construction phase are listed as follows:

• Use existing quarries, borrow sites and waste disposal sites. Avoid opening of new quarries. Where possible reuse excavated materials to minimize the need for opening a new quarry. However, if unavoidable, Construction Contractor shall obtain the relevant permit/license from the Ministry of Nature Protection and the Ministry of Energy and Natural Resources for the opening and operation of new quarries, before commencement of construction activities. • Construction Contractor shall obtain agreement from the relevant local/regional authorities (usually community administration) for disposal of excavated materials and construction wastes in the approved dump site. No waste shall be disposed into waterways, their beds, or in immediate proximity to them. Neither shall any waste be dumped into wetlands and flood plains. Burning of the waste shall be banned. • Choose and delineate carefully all access roads, work sites, construction materials storage and waste temporary accumulation sites. Manage and monitor these sites closely so that they do not expand unduly during construction; • In the areas designated for establishment of construction camps and storage sites the top layer of soil (typically about 20 cm) shall be scraped and stored in piles not exceeding one meter. After completion of works soil shall be used for site restoration; • Compact the top surface of access roads and work sites to facilitate water runoff and avoid flooding the area. This can require digging of drainage ditches and connecting them to existing drainage infrastructure; • Conduct dust-depressing measures aimed at prevention of air pollution through watering of access roads and construction site. During construction, air pollution levels will be increased mostly by machine operations for earthwork. The main pollutants caused by these operations include exhaust gases emitted by machines and dust caused by the earthwork. Water regular sprinkling during construction works will depress the dust, thus reducing impact on workers. Additional measures planned to maintain air quality include locating concrete mixing plant and stockpiles in isolated area, as well as confining working vehicles to designated routes only following the established schedule. Trucks loaded with loose construction materials (such as gravel, sand, soil, etc.) shall be covered to minimize dust emissions during transportation; • To reduce the likelihood of oil spillage from construction equipment and fecal contamination from construction camps, sites for these areas shall be carefully designated and proper technical condition of machinery and equipment shall be ensured. In addition, sand or fine gravel should be spread on the ground in the locations designated for parking, and servicing construction machinery. In case of spillage the polluted layer should be removed to the designated waste disposal site and replaced with new layer of sand or fine gravel; • Noisy plant and equipment must be sited as far as possible from noise-sensitive buildings. Barriers (e.g. site huts, buildings, fences) or purpose-built acoustic screens should be used to reduce the noise reaching sensitive buildings where practicable. Avoid the use of percussive and impact tools wherever possible. Vehicles and machinery should be fitted with effective exhaust silencers and maintained in good and

Environmental Impact Assessment and Environmental Management Plan Reports 38 Construction of multi-profile hospital in Gyumri city, Shirak region

efficient working order. Machinery in intermittent use should be shut down or throttled down to a minimum when not in use. • In case of chance finds during earthworks, the construction contractors shall cease the works and provide relevant information to the State Agency for Protection of Historical and Cultural Monuments which after due consideration of the findings, and the Agency experts after determining the significance of the chance finds shall recommend whether the works can be continued or the design must be revised. • Restoration to quasi-original conditions of landscape after completion of construction works and after use of quarries, where possible use the specific plant species typical for the Project area;

Mitigation measures proposed for the hospital operation phase include:

• Proper maintenance of water supply and wastewater system is very important in order to ensure provision of safe and reliable water supply and sewerage services. Regular maintenance checks of the system shall be performed to ensure its operation state. Drainage system installed at the hospital site shall be periodically cleaned to ensure proper water flow. • Regular check of proper technical conditions of vehicles and equipment shall be conducted to minimize emissions to atmosphere and prevent possible leakages of fuel and oil causing soil and water pollution. • Proper maintenance of boiler house to reduce volumes of emissions to atmosphere associated with operation of heating system and subsequent emission of pollutants originated during burning of fuel. • Ensure presence, proper maintenance and good conditions of health and safety equipment and tools (including availability of the adequate fire fighting equipment). Adequate access and egress shall be maintained as well as fire signage and emergency lighting shall be provided. Mechanism and plan of proper categorization and disposal of domestic and medical waste (including bio-hazardous waste (BHW), pathological waste, chemical and pharmaceutical waste (C&P waste)) shall be developed and implemented by the hospital administration. Disposal contracts will be signed with public waste disposal company. BHW shall be treated in-site or handed over to a licensed waste treatment & disposal company. The waste shall be either disinfected by steam (e.g. autoclaving) or shall be incinerated (either locally in a small-scale incinerator or centrally according to the appropriate contract). Disinfected waste and residues from the waste incineration shall be disposed of with the domestic healthcare waste. The treatment by chemicals shall be allowed only in exceptional cases (e.g. during transition phase).

C&P waste consist out of different kind of waste which need specific treatment methods. Pharmaceutical waste shall be incinerated; alternative solution can be the crushing and encapsulation or inertization of the waste to avoid the misuse of these items. Chemical waste from the radiology department (Fixing bath, developing bath, films) shall be sold for external treatment and silver recovery. Heavy metal containing chemical waste shall be accumulated until a solution for this type of waste exists in Armenia.

Environmental Impact Assessment and Environmental Management Plan Reports 39 Construction of multi-profile hospital in Gyumri city, Shirak region

Patho-waste shall be either incinerated (on-site or off-site) or shall be buried in approved burying places (off-site).

No radioactive waste will be produced by Gyumri Medical Center. Technical assistance activities as well as provision of HCWM supplies and equipment are planned under the project to ensure proper management of HCW.

Special traffic management signs shall be installed to regulate and maintain smooth traffic flow and avoid traffic jams as a result in increased traffic flow to hospital and operation of Ambulance vehicles.

Environmental Impact Assessment and Environmental Management Plan Reports 40 Construction of multi-profile hospital in Gyumri city, Shirak region

8. Public Consultations During the years 2004-2008 the draft program of optimization of Gyumri city hospital facilities underwent multiple discussions in the Ministry of Health, in Shirak regional Government and Gyumri hospital facilities in participation of Ministry of Health, regional government representatives, hospitals’ administration and staff members. As a result, the transfer of adult hospital services from three current hospitals of Gyumri-- Shirak Marz, Samariter and Gyulbenkyan Surgical Hospitals to a new adult hospital facility to be constructed next to the Austrian children’s hospital of Gyumri and thus concentration of all acute hospital care on one site was considered expedient and approved by the Government decree. That decision was as well in line with the recommendations of international experts of previous years, according to which the most optimal choice for organization of hospital services in Gyumri would be their concentration in a new-built hospital of appropriate size, as none of the existing hospitals’ infrastructure, even after rehabilitation would be appropriate for provision of hospital services of modern standards to the population of Gyumri city. The staff of the Austrian children’s hospital was informed on planned construction activities. Discussions held with of people leaving nearby the proposed construction place show that they were positive on the proposed project for construction of a new hospital. The other residential houses and service buildings are located in sufficient distance form the construction site and will not be adversely impacted by proposed project.

On December 18, 2009 the public consultation to discuss EIA and EMP reports developed for construction of a new hospital was held in Gyumri city of Shirak region. Representatives of HPIU, Public Environmental Information Centre (Aarhus Centre) of Gyumri, and 14 NGOs participated in the public consultation. The aim of the public consultations was to discuss the environmental and social issues related to the construction of a new hospital in Gyumri city. The overall description of the scope and activities to be implemented under the proposed project, details of the construction activities were presented during consultation in addition to a detailed presentation of the potential negative environmental and social impacts associated with the hospital construction, mitigation measures envisaged to prevent or minimize negative impacts, importance of the proposed project for the local people, as well as expected outcomes. Participants of the meeting emphasized the importance of a new hospital construction and expressed their expectation to more reliable provision of medical services. All questions were duly answered by representatives of HPIU. The Minutes of public consultation and scanned list of participants are presented in the Annex III.

Environmental Impact Assessment and Environmental Management Plan Reports 41 Construction of multi-profile hospital in Gyumri city, Shirak region

ANNEX I. REFERENCE LIST

1. Architectural design of Gyumri Medical Center of Gyumri City Shirak marz developed by “A3-Architects” LTD (10 volumes)

2. Armenian Ecotourism Association, http://www.ecotourismarmenia.com/index.html

3. Biodiversity of Armenia, http://www.nature-ic.am/biodiv/index%20eng.html

4. Climate Change Information Centre of Armenia, http://www.nature.am/ 5. Convention on Access to Information, Public Participation in Decision-Making and Access to Justice in Environmental Matters (1998); available online at: www.unece.org 6. Convention on Environmental Impact Assessment in a Transboundary Context (1991); available online at: www.unece.org 7. Construction norms and regulations volume II-L.9-70 Hospitals & Polyclinics; 8. Construction norms and regulations 2.08.02-89 Public buildings; 9. Credit # 4267 - AM Financing Agreement on the Armenia Health System Modernization ( PL2) signed on March 9, 2007 between Government of RA and the IDA; 10. Decree # 1911- N dated 02.11.06 of the Government of RA on “Optimization of the Marz Health Care Systems. 11. Draft National Water Program (2005), Developed by Institute of Water Problems and Hydraulic Engineering for the Ministry of Nature Protection of the Republic of Armenia, Yerevan, Armenia (in Armenian) 12. Environmental Impact Monitoring Centre of the Ministry of Nature Protection of the Republic of Armenia, Report on Surface Water State for 2008, Yerevan, 2009 (in Armenian) 13. Encyclopedia Soviet Armenia, Yerevan, Armenia, 1987 14. Environmental Research and Management Center of the American University of Armenia, http://enrin.grida.no/htmls/armenia/soe_armenia/english/ermcaua/ermc.htm 15. Fourth national Report to the Convention on Biological Diversity, Ministry of Nature Protection of the Republic of Armenia, Yerevan, 2009 16. Khandjyan N., Specially protected areas of Armenia, RA Ministry of Nature Protection, Yerevan, Armenia, 2004 17. Protocol on Strategic Environmental Assessment (Kiev, 2003); available online at: www.unece.org

18. Shirak regional management system, http://shirak.region.am/egov/dispatcher (in Armenian) 19. Ministry of Nature Protection of the Republic of Armenia, 1999, Armenia National Environmental Action Program. Main Report. 20. RA Constitution, 2005 (in Armenian) Environmental Impact Assessment and Environmental Management Plan Reports 42 Construction of multi-profile hospital in Gyumri city, Shirak region

21. RA Governmental Regulation on assessment of impact on atmosphere caused by economic activities, 25 January 2005, N91-N 22. RA Law on the Principles of Environmental Protection, 1991 (in Armenian) 23. RA Law on Ensuring Sanitary-epidemiological Security of the RA Population, 1992 (in Armenian) 24. RA Law on Atmospheric Air Protection , 1994 (in Armenian) 25. RA Law on Environmental Impact Assessment, 1995 (in Armenian) 26. RA Law on the Protection and Use of Fixed Cultural and Historic Monuments and Historic Environment, 1998 (in Armenian) 27. RA Law on Environmental and Nature Use Charges, 1998 (in Armenian) 28. RA Law on Rates of Environmental Charges, 2006 (in Armenian) 29. RA Law on Flora, 1999 (in Armenian) 30. RA Law on Fauna, 2000 (in Armenian) 31. RA Land Code, 2001 (in Armenian) 32. RA Law on Environmental Education, 2001 (in Armenian) 33. RA Water Code, 2002 (in Armenian) 34. RA Law on National Water Policy, 2005 (in Armenian) 35. RA Law on National Water Program, 2006 (in Armenian) 36. RA Code on Underground, 2002 (in Armenian) 37. RA Law on Wastes, 2004 (in Armenian) 38. RA Law on Environmental Monitoring, 2005 (in Armenian) 39. RA Law on Environmental Oversight, 2005 (in Armenian) 40. RA Forest Code, 2005 (in Armenian) 41. RA Law on Specially Protected Natural Areas, 2006 (in Armenian) 42. RA Law on Medical Care and Services to the Population (1996) 43. National Atlas of Armenia, Yerevan, Armenia, 2007

44. Rediscovering Armenia Guidebook - Shirak Marz, www.armeniapedia.org 45. Set of methodologies for calculation of pollutants emission into atmospheric air by different enterprises, Goskomgidromet, Leningrad, Russia, 1986 46. SNIP 1.02.01-85: Instruction on content, order of development, agreement and approval of design-tender documentation for construction of enterprises, buildings and structures. 47. SNIP 2.04.02-84: Water supply, External pipelines and structures 48. State of the Environment Report for Armenia, Year 2000, http://enrin.grida.no/htmls/armenia/soe2000/eng/

Environmental Impact Assessment and Environmental Management Plan Reports 43 Construction of multi-profile hospital in Gyumri city, Shirak region

49. Temporary methodological guideline on calculation of emissions of non-organized sources in construction industry, USSR Minpromstroy, Moscow, Russia, 1984 50. The Results of 2001 Census of the Republic of Armenia (Figures of the Republic of Armenia); State Committee on the Organization and Conduction of the RA Census 2001, National Statistical Service on the Republic of Armenia, 2003 51. Tour Armenia – Travel Guide, Shirak Marz. By Rick Ney, 2007 52. Water Quality and Quantity Stations in Armenia, Armhydromet Agency, www.meteo.am 53. Reference on State of Surface Water for 2008, developed by the EIMC of RA MNP, www.mnp.am

Environmental Impact Assessment and Environmental Management Plan Reports 44 Construction of multi-profile hospital in Gyumri city, Shirak region

ANNEX II. ENVIRONMENTAL MANAGEMENT PLAN

Mitigation and Monitoring Plans

Construction Contractor is responsible for implementation of mitigation measures provided in this EMP (see Table 1: Mitigation Table), as well as for obtaining all construction activities related permits and agreements. In order to prepare the Construction Contractor to fully understand and work in accordance with the EMP requirements the HPIU may organize and conduct the introductory meeting/training for the relevant personnel of Construction Contractors. If necessary, this meeting/training can include provision of some basic environmental knowledge as well as specific knowledge related to EMP implementation e.g. in prevention of damages on vegetation, transportation, handling and storage of construction materials and waste (including proper handling of the hazardous materials like oil, etc.).

Monitoring of the EMP will be carried out by the Supervision Contractor (to be hired by HPIU) and the Construction Supervision Unit headed by the Civil Works and Environmental Specialist of HPIU, as a part of overall supervision over construction activities. Along with other responsibilities the Supervision Contractor will be assigned to track compliance by the civil works contractors with the EMP. HPIU appropriate specialist will conduct periodical visits to construction sites to ensure proper implementation of EMP. HPIU specialist will also coordinate environmental training for staff, designers and local contractors to ensure proper understanding if environmental requirements. Monitoring of construction activities is required to assure that adverse environmental impacts are avoided and/or minimized as well as that adequate mitigation measures are properly implemented. Monitoring during the construction phase will be short-term and localized on hospital site boundaries. The monitoring process to be implemented in accordance with the Table 2: Monitoring Plan will be based on visual inspections of the materials used, construction practices, and mitigation methods applied during construction phase.

Estimated Cost

Estimated costs for the implementation of mitigation and monitoring plans are included in contract bids. In general the cost for implementation of mitigation measures is estimated to comprise about 2-3% of the total construction cost-estimate (up to approx. 200.000 USD). The real costs of the above measures are to be determined during the construction phase.

In the event of an accident or when is deemed necessary by HPIU and/or WB, appropriate samples shall be taken and analyzed to ensure no hazardous material is spread. If pollution occurred as a result of Construction Contractor’s fault, the Construction Contractor will cover the cost of analysis; otherwise HPIU will pay for the sampling and appropriate analysis. Mitigation measures to be implemented during operation phase (e.g.

Environmental Impact Assessment and Environmental Management Plan Reports 45 Construction of multi-profile hospital in Gyumri city, Shirak region maintenance of drainage system, etc.) are to be paid from operation and maintenance budget of operating agency.

Implementation Schedule and Reporting The following reporting requirements are scheduled to address the progress over implementation of the Environmental Management Plan.

1. Construction Contractor will report to HPIU on implementation of mitigation measures proposed in EMP (Table 1) on a quarterly basis. The sample format for reporting is presented below:

Mitigation Measures M 1 M 2 M 3 M 4 M 5 M 6 … … a. measure 1 ------b. measure 2 c. measure ... etc. 2. Supervision Contractor will use the Monitoring Plan framework presented in EMP (Table 2) to report the progress and compliance of the Construction Contractor with respect to implementation of mitigation measures. The following sample table could be used to report the progress to HPIU on a quarterly basis:

Monitoring parameters M 1 M 2 M 3 M 4 M 5 M 6 … … a. parameter 1 ------b. parameter 2 c. parameter ... etc. 3. In case of emergency the Construction Contractor/ Supervision Contractor shall fill the Incident Report Form presented in the Table 3 and submit it to HPIU.

In addition to above reports HPIU will prepare the reports outlining status of EMP implementation as part of the regular progress reporting. Such reports shall include information on any environmental issues arising from project-supported activities, the status of mitigation measures taken, and next steps, if any.

World Bank’s supervision reports (including Mid-Term Review and the Implementation Completion and Results report) will cover status of the project’s environmental performance.

Remedies for EMP Violation

Health PIU, as a client of construction works, will be responsible for enforcing compliance of contractor with the terms of the contract, including adherence to the EMP. For minor infringements, an incident which causes temporary but reversible damage, the contractor will be given 48 hours to remedy the problem and to restore the environment. If

Environmental Impact Assessment and Environmental Management Plan Reports 46 Construction of multi-profile hospital in Gyumri city, Shirak region restoration is done satisfactorily during this period, no further actions will be taken. If it is not done during this period, PIU will arrange for another contractor to do the restoration, and deduct the cost from the offending contractor’s next payment. For major infringements, causing a long-term or irreversible damage, there will be a financial penalty up to 1% of the contract value in addition to the cost for restoration activities.

Environmental Impact Assessment and Environmental Management Plan Reports 47 Construction of multi-profile hospital in Gyumri city, Shirak region

TABLE 1: Mitigation Plan

POTENTIAL NEGATIVE IMPACT ENVIRONMENTAL MITIGATION MEASURES EXECUTING SUPERVISING AGENCY AGENCY Construction Phase Pollution of water and soil as a result of Establish work site, install concrete-mixing plant as well as organize Construction Supervision civil works implementation, improper the site for construction materials storage that will cause no damage Contractor Contractor construction materials storage, to the vegetation cover and will prevent blocking the drainage water management and usage flow or adversely impacting water quality by construction run-off. Oils and lubricants (other liquid materials) shall be stored in closed tanks and at specially designated place to prevent leakage and to minimize pollution of soil and water in case of leakage. Sand or fine gravel should be spread on the ground in the locations designated for parking, and servicing construction machinery. In case of spillage the polluted layer should be removed to the designated waste disposal site and replaced with new layer of sand or fine gravel. The construction work sites and storage facilities must be effectively protected against spill. Ensure preservation of appropriate rules at the construction camps, Construction Supervision including control over incoming and outgoing vehicles, proper Contractor Contractor operation o drainage system, etc. At working site grease and oil discharges from machinery Construction Supervision maintenance and fecal contamination from the construction camp Contractor Contractor shall be prevented through regular check-up of the condition of machinery and equipment, and removal of polluted soil/sand in case of spill. Pollution of water and soil as a result of Establish the sites for preliminary accumulation of excavated Construction Supervision improper disposal of excavated materials and waste that will cause no damage to the vegetation Contractor Contractor materials and construction wastes cover and other components of the environment. Site for waste preliminary accumulation shall be clearly delineated Construction Supervision and their location shall be agreed with Supervisor. Such site shall not Contractor Contractor be established nearby the trees to avoid damaging them and nearby the water bodies to prevent possible water pollution by construction run-off.

Environmental Impact Assessment and Environmental Management Plan Reports 48 Construction of multi-profile hospital in Gyumri city, Shirak region

POTENTIAL NEGATIVE IMPACT ENVIRONMENTAL MITIGATION MEASURES EXECUTING SUPERVISING AGENCY AGENCY Arrange proper transport and disposal of excavation materials and Construction Supervision wastes to the approved dump sites designated for the specific Contractor Contractor purpose and agreed with local/regional authorities. No waste shall be disposed into waterways, their beds, or in immediate proximity to them. Neither shall any waste be dumped into wetlands and flood plains. Wherever possible excavated materials and waste shall be hauled directly to the approved disposal site to minimize double handling of the waste, site cleanup and dust generation. Temporary air pollution (dust) related to Use closed/covered trucks for transportation of construction materials Construction Supervision the transportation of construction (such as gravel, sand, soil, etc.) to the construction sites and/or Contractor Contractor materials/ waste and truck traffic removal of construction waste originated during implementation of civil works to approved dump site. When possible (warm and dry weather) wash the tires of trucks to minimize dust exposure. Maintain construction equipment to good standard, improper functioning machinery that causes excessive pollution will be banned from the construction site. Clean the surrounding area of the worksite from dust by regular water Construction Supervision sprinkling (during warm and dry months), removal of excess materials Contractor Contractor and cleaning of sites upon completion of activities.

Workers exposed to dust shall be provided with and use necessary Construction Supervision protection gear. Contractor Contractor Noise and vibration disturbances Terminate the works at the established time (e.g. work in daylight Construction Supervision time), and avoid increase of noise and number of peak hours. Contractor Contractor

Proper maintenance of machinery and vehicles should be ensured to keep the impacts as low as possible. Vehicles and machinery should be fitted with effective exhaust silencers and maintained in good and efficient working order. Machinery in intermittent use should be shut down or throttled down to a minimum when not in use. Noisy equipment must be sited as far as possible from the nearby buildings.

Environmental Impact Assessment and Environmental Management Plan Reports 49 Construction of multi-profile hospital in Gyumri city, Shirak region

POTENTIAL NEGATIVE IMPACT ENVIRONMENTAL MITIGATION MEASURES EXECUTING SUPERVISING AGENCY AGENCY Workers in the vicinity of sources of high noise/vibration shall wear Construction Supervision necessary protection gear (e.g. earplugs, etc.). Contractor Contractor The construction equipment will strictly conform to Armenian Construction Supervision standards. Regular checking of vehicle conditions to ensure Contractor Contractor appropriate use of mufflers, etc.

Impacts on archaeological sites Cease the works in case of a chance find during earthworks at the Construction Supervision construction site and provide relevant information to the State Agency Contractor Contractor for Historical and Cultural Monuments Protection. Landscape degradation and soil erosion Use excavated soil for backfilling, where possible. Construction Supervision Contractor Contractor Accumulate excavated materials and construction waste only in specially designated places. Restoration to quasi-original conditions of landscape after completion Construction Supervision of construction works and after use of quarries; restoration of the Contractor Contractor vegetation cover. Plant species characteristic to the landscape of the construction site shall be used in the course of restoration of the vegetation cover. Safety issues Provide workers with safety instructions and protective equipment as Construction Supervision required by local laws. In some cases appropriate guidance shall be Contractor Contractor given to the workers in charge of handling oil, chemicals or dealing with hazardous materials, etc. Appropriate traffic signs shall be installed at the nearby roads to be intensively used for transportation of construction materials and/or construction waste to ensure smooth flow of transport/vehicles. In some cases a flagman or traffic control supervisor shall be engaged. Operation Phase Flooding and water pollution as a result Water supply, sewerage systems installed at the hospital shall be Relevant City hall of improper maintenance of water periodically cleaned to ensure provision of safe and reliable water department of supply, wastewater and drainage supply and sewerage services. Regular maintenance checks of the city hall systems system shall be performed to ensure its operation state. Drainage system installed at the hospital site shall be periodically cleaned to ensure proper water flow. Environmental Impact Assessment and Environmental Management Plan Reports 50 Construction of multi-profile hospital in Gyumri city, Shirak region

POTENTIAL NEGATIVE IMPACT ENVIRONMENTAL MITIGATION MEASURES EXECUTING SUPERVISING AGENCY AGENCY Potential pollution as a result of non- Timely transportation and disposal of waste shall be arranged to Hospital City hall timely waste disposal prevent over-accumulation of waste on-site and possible subsequent pollution of water and soil.

Mechanism of proper categorization and disposal of domestic and medical waste shall be developed and implemented in the hospital.

Domestic waste shall be properly collected and timely transported to disposal site agreed with City hall.

For handling the medical waste, administration of the hospital shall sign the agreement with special licensed organization(s) to be responsible for such waste collection, transportation and handling in accordance with RA relevant legislation. Emission to atmosphere from boiler Ensure proper maintenance of boiler house to reduce volumes of Hospital MoNP house emissions to atmosphere associated with operation of heating system and subsequent emission of pollutants originated during burning of fuel, Timely provision of compulsory payments for harmful substances emissions, surface and underground water pollution with wastewater, pollution of other components of environment in accordance with RA Law on Environmental and Nature Use Charges and RA Law On Rates of Nature Protection Payments.

Safety issues Ensure presence, proper maintenance and good conditions of health Hospital Fire-protection and safety equipment and tools (including availability of the adequate department of fire fighting equipment). Adequate access and egress shall be the Ministry of maintained as well as fire signage and emergency lighting shall be Emergency provided. Management (MoEM)

Traffic jams as a result in increased Special traffic management signs shall be installed to regulate and Road police RA police traffic flow to hospital and operation of maintain smooth traffic flow. Ambulance vehicles

Environmental Impact Assessment and Environmental Management Plan Reports 51 Construction of multi-profile hospital in Gyumri city, Shirak region

TABLE 2: Monitoring Plan

PHASE WHAT PARAMETER WHERE THE HOW THE PARAMETER WHEN THE PARAMETER* REPORTING is to be monitored? PARAMETER is to be monitored? is to be monitored? AGENCY is to be monitored? Type of monitoring equipment (frequency of measurement or continuously)

Construction Material borrow sites and At the Construction Permits from Ministry of Nature After signing a contract, Supervisor quarries Contractor Protection (in case the opening prior to commencement of of a new quarry is required) civil works and opening of a new quarry

Agreement for waste At the Construction Agreement with local/regional Prior to waste transportation Supervisor disposal Contractor authorities (community leader) to dump site and disposal

Soil erosion In new cutting areas Inspections at site During construction works Supervisor and after the restoration of site is finished

Water pollution In the nearby Inspections at site, analysis of During construction, when Supervisor water bodies water samples (water quality pollution by construction run- basic parameters, organics) offs to nearby water objects in an approved laboratory is observed

Proper storage of At work site in case it is Inspection During construction works, Supervisor construction materials, fuel, used for storing of when work site areas are oil, etc. construction materials, used for storing construction fuel, oil, etc. materials, fuel, oil, etc. Air pollution/dust At work site Inspections at site to make sure During civil works Supervisor that the site is regularly watered and that dust is not significantly affecting the workers Inspections at site. Noise and vibration At work site Check of vehicles/machinery During earthworks. Supervisor technical conditions. On complaint. Measurement of noise level with portable (hand-held) device.

Environmental Impact Assessment and Environmental Management Plan Reports 52 Construction of multi-profile hospital in Gyumri city, Shirak region

PHASE WHAT PARAMETER WHERE THE HOW THE PARAMETER WHEN THE PARAMETER* REPORTING is to be monitored? PARAMETER is to be monitored? is to be monitored? AGENCY is to be monitored? Type of monitoring equipment (frequency of measurement or continuously)

Maintenance of construction At work site Inspection During construction works Supervisor sites, machinery, and after restoration of construction materials construction sites storage and waste accumulation sites, etc.

Site safety (presence of At work site Inspection During construction works Supervisor relevant warning signs, fire- fighting equipment, first-aid kit)

Personnel safety (availability At work site Inspection During construction works Supervisor and use of relevant safety uniform)

Overall workers’ camp site At work site Inspection According to the existing Supervisor conditions regulations

Accidents at work site At work site Accident report When accident occur Supervisor including those with (see: EMP Table 3) environmental hazardous materials1

Operation Accidents with hazardous At accident site Accident report Immediately after Traffic Police materials or wastes an accident MNP, MH

Disposal of domestic waste At hospital site Inspection During operation City hall

1 In the case of accident should be filling accident reporting form Environmental Impact Assessment and Environmental Management Plan Reports 53 Construction of multi-profile hospital in Gyumri city, Shirak region

PHASE WHAT PARAMETER WHERE THE HOW THE PARAMETER WHEN THE PARAMETER* REPORTING is to be monitored? PARAMETER is to be monitored? is to be monitored? AGENCY is to be monitored? Type of monitoring equipment (frequency of measurement or continuously)

Disposal of medical waste At hospital site Inspection During operation City hall, MoH, MoEM

Maintenance of water At hospital site Inspection According to operational City hall supply, wastewater and guidelines of the water drainage systems supply/wastewater company as well as relevant department of City hall

Maintenance of traffic flow At streets nearby the Inspection According police rules Road Police hospital site

Timely implementation of At hospital Inspection Payments – on annual MoNP compulsory payments for basis, according to RA law nature use

* Monitoring reports will be developed on quarterly basis as is stated in EMP Section on “Implementation Schedule and Reporting”.

Environmental Impact Assessment and Environmental Management Plan Reports 54 Construction of multi-profile hospital in Gyumri city, Shirak region

TABLE 3: Accident Report Form

ACCIDENT REPORT FORM Traffic accidents and environmental accidents such as spills, etc.

CONSTRUCTION OF HOSPITAL IN GYUMRI CITY

1 Date: 2 Region: Shirak 3 Location: Gyumri city 4 Hospital: 5 Construction Contractor: 6 Accident Type: High 7 Severity: Medium Low Yes 8 Damage to third party: No 9 Reported By: 10 Description of Incident Root Cause: 11 Corrective Action Taken: 12 Corrective Action to be Taken: 13 Action Taken to Prevent Recurrence: 14 Corrective Action Carried Out By: 15 Close Out By: 16 Close Out Date: 17 Person Involved: 18 Machine Involved: 19 Contractor/Sub Contractor Involved: 20 Third Party Involvement: The photos with appropriate descriptions 21 Photo Reference – Attached: should be presented as an Attachment to the Incident Report

For HPIU use only Date Received by: Decision/Action made:

Environmental Impact Assessment and Environmental Management Plan Reports 55 Construction of multi-profile hospital in Gyumri city, Shirak region

ANNEX III. MINUTES OF PUBLIC CONSULTATION

On December 18, 2009 the public consultation to discuss EIA and EMP reports developed for construction of a new hospital was held in Gyumri city of Shirak region. Representatives of HPIU, Public Environmental Information Centre (Aarhus Centre) of Gyumri, and 14 NGOs participated in the public consultation.

The consultation was aimed at discussing environmental and social issues related to the construction of a new hospital in Gyumri city. The meeting was organized with the presentation and the discussion of the overall description of the activities to be implemented within the scope of the proposed project, the details of the proposed construction activities, potential negative environmental and social impacts, envisaged mitigation measures envisaged to prevent or minimize adverse impacts, importance of the project activities for the local people as well as expected outcomes. It was mentioned that the proposed project is not expected to have any significant and irreversible adverse impacts on the human health and the natural environment.

Modest and temporary negative environmental impacts may be caused both during implementation of construction works and further during operation of hospital. The main expected impacts during the implementation period include degradation of landscape and soil due to clearing of vegetation, opening/operation of earth borrow and quarry pits, improper disposal of excavated materials and construction waste; pollution of water resources and soil by construction run-offs; spillage of oil and other substances during the construction; and generation of noise and dust from operation of construction machinery. During operation period the likely adverse impacts include emissions to atmosphere associated with operation of heating system; impacts on water and soil as a result of improper maintenance of water supply, wastewater and drainage systems, vehicles and equipment, boiler house and electrical sub-station; impacts from waste improper categorization.

Meantime, the long-term social impacts of the proposed project are overall positive due to provision of reliable, timely and high-quality primary health care services on the basis of family medicine; provision of a wide range of healthcare services in one medical center; improved access to quality health care services provided to the population, in particular the most vulnerable groups; reduction of hospital operation and maintenance costs; creation of new employment opportunities; overall improvement of the socio-economic situation and population welfare. No land acquisition will occur while constructing the new hospital in Gyumri city.

Participants of the meeting were interested on the reasons of choosing the alternative to construct a new hospital instead of reconstructing one of the existing facilities, organization to be hired to implement the construction activities, restoration and greening activities to be conducted after the completion of construction works, location of the construction waste disposal site as well as whether the wastes originated during the operation of the hospital will be properly disposed,

Participants of the meeting emphasized the importance of a new hospital construction and expressed their expectation to reliable provision of medical services. All questions were

Environmental Impact Assessment and Environmental Management Plan Reports 56 Construction of multi-profile hospital in Gyumri city, Shirak region duly answered by representatives of HPIU. The scanned list of participants of the public consultation is presented below.

Environmental Impact Assessment and Environmental Management Plan Reports 57 Construction of multi-profile hospital in Gyumri city, Shirak region

Environmental Impact Assessment and Environmental Management Plan Reports 58 Construction of multi-profile hospital in Gyumri city, Shirak region

Environmental Impact Assessment and Environmental Management Plan Reports 59 Construction of multi-profile hospital in Gyumri city, Shirak region

Environmental Impact Assessment and Environmental Management Plan Reports