LAO PEOPLE’S DEMOCRATIC REPUBLIC Peace Independence Democracy Unity Prosperity MINISTRY OF HEALTH Department of Health Care and Rehabilitation (DHR) Lao PDR COVID-19 Response Project (P173817) and Additional Financing (P175771) Site–Specific ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN for SEKONG PROVINCIAL HOSPITAL, SEKONG PROVINCE 23 February 2022 Table of Contents EXECUTIVE SUMMARY ...................................................................................................................................4 ABBREVIATIONS AND ACRONYMS ...............................................................................................................8 CHAPTER 1. INTRODUCTION ........................................................................................................................ 11 1.1. PROJECT BACKGROUND AND ESF REQUIREMENT .............................................................................................. 11 1.2. ESMP PREPARATION APPROACH ................................................................................................................. 12 1.3. OBJECTIVE AND SCOPE OF SS-ESMP ............................................................................................................ 13 CHAPTER 2. DESCRIPTION OF PROJECT .................................................................................................... 13 2.1. GENERAL DESCRIPTION .............................................................................................................................. 13 2.2. DESCRIPTION OF THE PROPOSED HCF IN SEKONG PROVINCIAL HOSPITAL ............................................................... 14 CHAPTER 3. NATIONAL LEGISLATIONS AND ESMF REQUIREMENTS ..................................................... 18 3.1. NATIONAL LAWS AND REGULATIONS ....................................................................................................... 18 3.2. ESMF REQUIREMENTS AND ES SCREENING ..................................................................................................... 19 CHAPTER 4. ENVIRONMENTAL AND SOCIAL CONDITIONS ...................................................................... 20 4.1 SOCIAL OVERVIEW ..................................................................................................................................... 20 4.2 ENVIRONMENTAL OVERVIEW................................................................................................................. 21 CHAPTER 5. RISKS, IMPACTS, AND MITIGATION MEASURES .................................................................. 24 5.1 RISKS AND IMPACTS AND MITIGATION MEASURES DURING CONSTRUCTION STAGE ............................................. 24 5.2 RISKS, IMPACTS, AND MITIGATION MEASURES DURING OPERATIONAL STAGE .................................................... 30 `5.2.1 Healthcare Waste Management (HCWM) ..................................................................................... 31 5.2.2 Healthcare Wastewater Treatment System .................................................................................... 35 5.3 POTENTIAL IMPACTS ON SOCIAL ISSUES, HEALTH, SAFETY, AND CLIMATE CHANGE ..................................................... 36 5.4 SUMMARY OF IMPACTS AND PROPOSED MITIGATION MEASURES .......................................................................... 38 CHAPTER 6. STAKEHOLDER ENGAGEMENT & INFORMATION DISCLOSURE .......................................... 39 6.1 STAKEHOLDER ENGAGEMENT ....................................................................................................................... 39 6.2 COMMUNITY RELATIONS AND SAFETY DURING CONSTRUCTION ............................................................................. 43 6.3 COMMUNITY RELATIONS AND SAFETY DURING OPERATIONS ................................................................................. 43 CHAPTER 7. RESPONSIBILITY OF KEY ACTORS FOR HCF CONSTRUCTION AND OPERATION ............... 44 7.1 IMPLEMENTATION AND ARRANGEMENT OF RESPONSIBLE ACTORS .......................................................................... 44 7.2 CAPACITY BUILDING ................................................................................................................................... 47 CHAPTER 8. GRIEVANCE REDRESS MECHANISM..................................................................................... 48 8.1 GRM PRINCIPLES. ..................................................................................................................................... 48 8.2 GRM FOR COMMUNITY .............................................................................................................................. 48 8.3 GRM FOR HEALTHCARE PROFESSIONALS AND CONTRACTORS’ WORKERS: ................................................................. 49 8.4 GRM FOR SEA/SH VICTIMS: ....................................................................................................................... 50 CHAPTER 9. ESMP MONITORING AND REPORTING................................................................................... 51 9.1 CONTRACTOR MONITORING ......................................................................................................................... 52 9.2 NON-COMPLIANCE REPORTING PROCEDURES ................................................................................................... 54 9.3 MONITORING AND REPORTING DURING OPERATIONS ......................................................................................... 54 CHAPTER 10. IMPLEMENTATION COSTS AND BUDGET ............................................................................. 54 10.1 COSTS. ................................................................................................................................................. 54 10.2 BUDGET: ............................................................................................................................................... 55 2 List of Figure Figure 1 Commitments and timebound for SS-ESMP implementation................................................ 7 Figure 2 - Location of Sekong Provincial Hospital in Sekong Province ............................................ 15 Figure 3 – Existing Plan .................................................................................................................. 16 Figure 4 – Layout Plan and Green Area ........................................................................................... 17 Figure 5 - Location of Landfill......................................................................................................... 22 Figure 6 - Sewage and Wastewater Treatment System ..................................................................... 35 Figure 8 Sequence of documentation requirement for HCFs construction ......................................... 37 List of Tables Table 1 Tentative Construction Plan ................................................................................................ 17 Table 2 Capacity of Septic Tanks..................................................................................................... 35 Table 3 Summary of issues and actions to be conducted for the proposed HCFs ............................... 38 Table 4 Consultation Plan for the SS-ESMP for the HCF in Sekong Provincial Hospital .................. 41 Table 5 Monitoring Plan – Construction Phase (CSC is PiSECCON) ............................................... 52 List of Annexes Annex 1: Project Description and National Regulations to be Applied 58 Annex 2: Design Concept, Drawings, and Photo of the Proposed HCF 69 Annex 3: ES Screening Results and MOH Regulations to be Applied 75 Annex 4: ES Information related to the Proposed HCF 85 Annex 5: Risks, Impacts, and Proposed Mitigation Measures during Construction Phase 92 Annex 6: Risks, Impacts, and Proposed Mitigation Measures during Operational Phase 134 Annex 7: Indicative Forms for GRM and Accident Reporting 201 Annex 8: Summary of the SS-ESMP Consultation 208 Annex 9: Lao PDR National Environmental Standards (Revised 2017) 218 3 Executive Summary Introduction 1. This document is a site-specific Environment and Social Management Plan (SS-ESMP) for the new healthcare facility (HCF) proposed to be constructed and operated in Sekong Provincial Hospital, Lamam District, Sekong province. This HCF aims to provide treatment services for COVID-19 patients. The SS-ESMP identifies environment and social (ES) risk of the proposed HCF during construction and operational stages as well as identifying measures to mitigate and/or manage them. The SS-ESMP is prepared in accordance with the relevant template and technical guidelines provided in the Environment and Social Management Framework (ESMF) of the Lao Covid-19 Response Project and its Additional Financing (herein after the Project) 1. 2. The Department of Healthcare and Rehabilitation (DHR) of the Ministry of Health (MOH) in close cooperation with the Project Coordination Office (PCO) of the Department of Planning and Cooperation (DPC) and other technical departments of MOH and the HCF owner will be responsible for implementation of the SS-ESMP after the construction has been completed. Project activities 3. Main activities of the proposed HCF comprises construction of four new one-story buildings at the existing Sekong Provincial Hospital (SPH) for COVID-19 treatment taking into account specific requirements. The new buildings comprise four main buildings: for one intensive care unit (ICU) (6 beds, 311 m2), one isolation ward (16 beds, 980 m2), one laboratory (206 m2), laundry (70 m2) and one for waste storage area (32 m2). With the existing 8 beds for COVID-19 treatment, the SPH will have a total of 30 beds when the new HCF is completed for COVID-19 treatment. The construction will be made inside the existing premises of the SPH; no land acquisition and/or physical resettlement will be required. 4. Detailed designs for these new buildings have been discussed and agreed with the WB technical team, including those related to ventilation, water and power supply, and technology and designs to ensure safe and effective management of solid and liquid wastes to be generated from the proposed HCF during operational phase. Management of healthcare solid and liquid wastes will take into account the application of key MOH regulations and specific requirements to prevent and control possible infection of COVID-19.. It is expected that construction will begin in late December 2021 as soon as the wet season is over. Chapter 2 and Annex 2 present the proposed activities in more details. ES risk screening and scope of the ESMP 5. As required by the ESMF, PCO conducted an environment and social (ES) screening of the proposed HCF in August 2021. After consultation with the World Bank (WB), it was concluded that the rating of ES risks of the proposed HCF is “substantial”. This is because there are potential constraints related to safe and effective operations of the HCF such as limited capacity of existing HCF owner, small operating budget, management and operational challenges during initial stage of the operation of the 1 Particularly Annex II (ES screening), Annex III (ESMP), Annex IV (ICWMP), Annex V (LMP), and Annex VI (ESCOP). 4 proposed new HCF due to increased number of patients, and limited waste management capacity in Lao PDR, and so forth. 6. Chapter 4 and Annex 4 present the ES existing conditions, including healthcare waste management (HCWM) in the proposed HCF area while Chapter 5 presents and discusses the ES risks in detail and proposed mitigation measures with more details provided in Annexes 5 and Annex 6. The key findings suggested that most of the risks and impacts during construction phase will be moderate, localized, temporary, and can be mitigated through effective planning, management, and monitoring of contractor performance during construction. However, the risks during operations can be substantial (see paragraph 5 above). 7. During the technical discussion between WB and MOH teams, efforts have been made to ensure that the proposed HCF are properly designed and that there are regulations, standard operation procedures (SOPs), and budget for training, operations and maintenance, including necessary equipment, PPEs, chemicals, and other consumable materials, etc. This is to ensure safe and effective operations of the proposed HCF. This site specific ESMP shall be cleared by the WB and key E&S requirements will be incorporated into the contracts with Contractors before starting the construction. The SS-ESMP has taking into account the technical guidance provided in the ESMF of the Project, the needs and constraints during the COVID-19 restriction by the GOL as well as the scope of the technical assistance (TA) to be implemented under Component 4 of the Project. Proposed mitigation measures during construction phase 8. Risks and mitigation measures during construction phase are discussed in Chapter 5 and detailed in Annex 5. Key risks, potential impacts, and mitigation measures are related to demolition of existing buildings, excavation and construction activities, labor and working conditions, occupational health and safety (OHS) and community health and safety (CHS) for project personnel and local communities, including risks of contracting and transmission of COVID-19 during procurement and delivery of goods and services process, and during organization of training sessions. 9. To mitigate these risks, the mitigation measures is proposed in Annex 5 and those to be implemented by contractor has been included as the ES obligations (ESO) in the contract document (CD). To ensure safety of the patients, visitors, and health staff during construction process, the contractor is required to install/erect safety fence/wall with appropriate warning signs (visible during day and night) around the construction sites before construction begins. Risks due to unexploded ordinance (UXO) is expected to be low however a small budget has been allocated in the contract for undertaking a technical survey for UXO screening at the proposed construction site. The use of security personnel is not expected at this stage. However, if there is a need later on, a plan for using security personnel will be prepared and submitted to the Bank for prior review before implementation. 10. In response to the second wave of COVID-19 pandemic in Lao PDR, MOH has accelerated the contractor selection and construction is expected to complete within 6- 7 months (starting November 2021). Before commencing construction, PiSECCON will provide training on the ESO to be implemented by the contractor and its staff and workers. PiSECCON will be responsible for day-to-day supervision and monitoring of the contractor’s performance and will report regularly the implementation progress to PCO, relevant responsible agencies, and the WB. 5 Proposed mitigation measures during operational phase 11. Key risks related to OHS, CHS, and HCWM are also expected during the operations of the proposed new HCF and the key ones are identified in Table A6.1 of Annex 6. PCO, DHR, and other related agencies will be jointly responsible for implementation of these proposed measures taking into account the relevant MOH regulations and recommendations provided by the WHO on management of medical wastes in Lao PDR. The risks and impacts related to air circulation, possible infection, water supply, and waste management (solid, medical, liquid) have been addressed through detailed design. In addition, as part of the on-going technical discussion on scope and implementation arrangement of the TA to be implemented under Component 4 of the Project, the needs for updating the existing MOH regulations and SOPs as well as for equipment and operational budget necessary to address issues related to CHS, infection prevention and control (IPC) procedures, HCWM, and operations and maintenance (O&M) have also been discussed. 12. Key mitigation measures proposed for IPC and HCWM include (a) provision of at least one autoclave for sterilization of infection waste before final off-site disposal and (b) provision of appropriate PPEs, waste bins, bags, safety boxes, chemicals and consumable materials, etc. necessary for safe handling of COVID-19 related wastes by staff and workers responsible for HCWM. It has been agreed that as soon as the construction of the proposed HCF is completed, the existing MOH regulations and SOPs will be first applied to the proposed HCF. At the moment, MCHC and DHHP have completed development of various SOPs for vaccination program as well as guidelines for hygiene and disinfection for HCF. These activities come under the TA Component 4) that aims to update existing regulations and SOPs before operation of the proposed HCF to ensure that it meets specific requirements of COVID-19, taking into account the technical guidelines provided in Annexes III and IV of the Project’s ESMF (see Annex 6 attachment 1) and the implementation experience and specific requirements for COVID-19. 13. It is important that the PCO ensures adequate budget is allocated and available for effective operations of the HCF at least until the end of 2023 (Project closing date). It is expected that this TA will also provide supports to facilitate the planning and implementation of the mitigation measures to address issues during operations of the proposed HCF related to CHS, climate change, flooding, emergency preparedness and response plan, and other key social aspects including those related to exclusion of vulnerable or disadvantaged groups. As part of the TA process, the Bank will review the TOR for any relevant technical studies and/or make recommendations. 14. It is expected that the on-going discussion on the mitigation measures during operations of the proposed HCF (discussed above) will be completed by the end of 2021 and the proposed Table A6.1 in Annex 6 of this SS-ESMP will be updated, as needed, including clarity on budget allocation. Stakeholder Engagement, Implementation Arrangement, GRM, Monitoring and Reporting 15. It is important that the HCF owner and/or MOH technical departments provide timely, appropriate and effective information and knowledge (including provision of trainings) to staff and workers of the proposed HCF, including patients, visitors, and local communities on safety aspects to enable these stakeholders to protect themselves during the operation phase of the new HCF (including during construction phase). 16. Chapter 6 identifies the actions related to stakeholder engagement, including information disclosure while Chapter 7 describes implementation arrangement for this SS-ESMP. PCO assisted by consultants have been facilitating the procurement and 6 contract signing on behalf of the DHR and will also be responsible for supervise and monitor the implementation of the proposed mitigation measures. The HCF owner is responsible for operations of the proposed HCF, however, with technical and financial supports from PCO, DHR, DHHP, and other related agencies. 17. Chapter 8 provides the project’s GRM, including site-specific GRM to established at PHO/DHO in Sekong before construction begins. Chapter 9 discusses arrangement for monitoring the SS-ESMP implementation, including reporting back to project stakeholders of consultation results as well as grievances. PCO submit SS- Detail design, Construction O-ESMP Technical ECC and Applied ESMP to WB for work, Apply specification and CD Construction (Operational Approval C-ESMP Started Cleared Permit Obtained Phase) 30 Nov 21 30 Nov 21 15 Dec 21 Jan-June 22 July22-Dec 2023 Figure 1 Commitments and timebound for SS-ESMP implementation Implementation budget 18. Chapter 10 taps into estimated cost for the SS-ESMP and source of budget for implementation. The budget for implementation of the SS-ESMP is being discussed with PCO and the technical agencies in light of the on-going discussion on the TA to be implemented under Component 4. It is expected that about US$50,000 of the Project budget will be made available for ensuring safe and effective operations of the proposed HCF and this will be confirmed byQ1- 2022. Information disclosure of the SS-ESMP 19. The Executive Summary of the SS-ESMP was disclosed on the Lao Health Planning and Project Management website before virtual consultations were carried out by PCO with local authorities and local community in Lamam district, Sekong province in early October 2021. PCO has led the consultation meeting with virtual participation of PCO, DHHP, and DHR. Because of COVID-19 restriction on social gathering, consultation with local people were conducted through use of Google Meet meeting. Feedbacks from local people were collected by local leaders, if any. The participants supported the construction of the proposed HCF and mitigation measures. Their feedback and key concerns have been incorporated in the final draft SS-ESMP (See consultation summary in Annex 8). 7 Abbreviations and Acronyms ACM Asbestos containing materials ADB Asian Development Bank AF Additional Financing APH Attapeu Provincial Hospital ATP Attapeu province CD Contract document CCEH National Center for Communication and Education for Health C-ESMP Environmental and Social Management Plan for Construction CHS Community health and safety CPS Champasack province CSC Construction supervision consultant DCDC Department Communicable Disease and Controlled DHHP Department of Hygiene and Health Promotions DHO District Health Office DHR Department of Health Care and Rehabilitation DPC Department of Planning and Corporation E&S Environment and Social ESO Environment and Social Obligations ESCOP Environment and Social Code of Practice SCOC Social Code of Conduct EHS Environmental, Health, and Safety EOC Emergency Operating Committee EPRP Emergency Preparedness and Response Plan ESCP Environment and Social Commitment Plan ESF Environmental and Social Framework ESHS Environmental, Social, Health and Safety ESMF Environmental and Social Management Framework ESMP Environmental and Social Management Plan ESS Environmental and Social Standards FDD Food and Drug Department GOL Government of Lao People's Democratic Republic (Lao PDR) GRM Grievance Redress Mechanism HCF Health-Care Facility 8 HCWM Health-Care Waste Management HCWMP Healthcare Waste Management Procedures HDPE High Density Poly Ethylene (HDPE) HVAC Heating ventilation and air conditioning system ICWMP Infection Control and Waste Management Plan ICU Intensive Care Unit IEE Initial Environmental Examination IPC Infection and Prevention Control Lao PDR Lao People's Democratic Republic LA/LC Local authorities and local communities LCRP Lao PDR COVID-19 Response Project LMP Labor Management Procedures MEP Mechanical, Electrical and Plumbing MOH Ministry of Health MCHC Mother and Child Healthcare Centre NCLE National Center for Laboratory and Epidemiology NRA National Regulatory Authority O-ESMP Environmental and Social Management Plan for Operation OHS Occupational Health and Safety PCO Project Coordination Office of DPC PHO Provincial Health Office POM Project Operation Manual PPE Personal Protective Equipment SARI Severe Acute Respiratory Infections SCOC Social Code of Conduct SEA Sexual Exploitation and Abuse SEP Stakeholder Engagement Plan SH Sexual Harassment SK Sekong Province SPH Sekong Provincial Hospital SOP Standard Operating Procedure SS Site-specific STI Sexual Transmitted Infection TA Technical Assistance 9 TD/CD Tender document and contract document UNICEF United Nations Children's Fund VAC Violence Against Children WB World Bank WHO World Health Organization 10 CHAPTER 1. INTRODUCTION 1.1. Project Background and ESF Requirement 20. Project background. The Government of Lao PDR (GOL) has been implementing the Lao PDR COVID-19 Response Project (LCRP) since April 7, 2020, with additional financing (AF) effective since July 22, 2021(hereinafter referred to as “the Project”). The total cost of the Project is USD 33 million, including USD 28 million provided by the World Bank (WB) and USD 5 million as a grant under the Health Emergency Preparedness Response (HEPR) Trust Fund. The Project aims to strengthen the capacity of the GOL in response to COVID-19 pandemic through procurement and deployment of COVID-19 vaccine. The activities have been designed on the basis of ongoing activities with adjustment made to Project components, activities, and associated costs (See Annex 1 for more information about the Project components, implementation arrangement, and budget allocation as well as the national legislation to be applied under the Project. 21. ESF requirements. To ensure that the environment and social risks and impacts identified are adequately managed during the Project implementation, the Environment and Social Framework (ESF) of the WB is applied. Of the total ten Environment and Social Standards (ESS) described in the WB’s ESF, six ESSs were deemed relevant to the Project including ESS1 (Assessment and Management of Environmental and Social Risks and Impact), ESS2 (Labor and Working Conditions), ESS3 (Resource Efficiency and Pollution Prevention and Management), ESS4 (Community Health and Safety), ESS7 (Indigenous People/Sub-Saharan African Historically Underserved Traditional Local Communities), and ESS10 (Stakeholder Engagement and Information Disclosure). The Environment and Social Managemental Framework (ESMF), Stakeholder Engagement Plan (SEP), and Environment and Social Commitment Plan (ESCP) prepared for the LCRP Project were updated to reflect additional activities under the additional financing (AF). 22. The AF has been cleared by WB before appraisal in May 2021. The Project Operation Manual (POM) was also updated to reflect the addition and adjustment of activities to be carried out under the Project. The PMU was cleared by the WB on 1st August 2021. As a result, a retroactive financing has been provided to support eligible activities that were implemented before the effective date of the Additional Financing, including updating of the existing ESF documents prepared under the parent Project to reflect most updated activities that will be carried out under the Project). 23. For the new Healthcare Facilities (HCF) to be constructed in three provinces, including Champasak (CPS), Attapeu (ATP), and Sekong (SK), the first meeting was conducted on 29 June 2021 to discuss about the detailed design for the HCFs which were prepared and submitted by PiSECCON (design consultant). The meeting focused on technical aspect of the detailed design for the HCFs, including proposed layout, structural design, ventilation, key facilities, etc. to be installed to handle solid and liquid waste management, as well as procurement arrangements. Feedback has been provided to the design consultant. The second technical meeting was conducted on 29 July 2021 to 11 discuss about the revised technical design and the first draft of Environmental and Social Management Plan (ESMP) – prepared for the three HCFs. 1.2. ESMP Preparation Approach 24. Number of meetings have been organized between the Project Coordination Office (PCO) of the Department of Planning and Cooperation (DPC) and the WB teams on the detailed design of the proposed HCFs, procurement selection and approach, scope and approach of the SS-ESMP preparation, and how consultation with local authorities and local communities (LA/LC) would be organized, especially in light of GOL regulations and restriction on COVID-19. This is to ensure safe and effective operations of the proposed HCF after construction is completed. 25. Key agreements made at the technical meeting on 10 August 2021 on the scope and approach for the preparation of the SS-ESMP is provided in Box 1.1 Box 1.1 Agreement during the meeting on 10 August 2021 1. The SS-ESMP will be prepared for each HCF in accordance with the guidance and requirements set out in the Project’s ESMF, SEP and ESCP taking into account the most updated regulations of the GOL and MOH, especially those related to healthcare waste management (HCWM); Occupational Health and Safety (OHS); safety of workers, local communities, and the general public; and those related to social aspects. 2. The SS-ESMP will identify key risks and impacts during both construction and operational phases of the proposed HCFs and propose measures to avoid, minimize, and/or mitigate them and provide information on the implementation and monitoring arrangement and budget allocation. 3. The SS-ESMP will be consulted with LA/LC and key stakeholders before it is finalized and submitted to WB for clearance. WB clearance is required before implementation. For each HCF, construction can begin after an Environmental Compliance Certificate (ECC) has been issued by the provincial Office of Natural Resources and Environment (PONRE). 4. The SS-ESMP for construction phase should focus on mitigating potential ES risks and impacts during site clearance, construction, and site closure. As part of the SS-ESMP, an Environmental and Social Code of Practice (ESCOP) have been developed and included in the Contract Document (CD) and PiSECCON will be responsible for day-to-day supervision and monitoring of the contractor performance on implementation of the ES measures. 5. Given limited capacity and budget of the HCF owner, it is necessary for PCO to lead the discussion with the key technical departments of MOH (especially DHR and DHHP) for technical guidance on how to ensure safe and effective operations of the proposed HCF before construction is completed. Since there are many agencies involved in the discussion and decision-making process and the on-going discussion between the WB and MOH teams on scope of the technical assistance (TA) to be implemented under Component 4 of the Project, it is expected that the SS-ESMP for operations will be finalized by end of 2021. 6. PCO (assisted by the ESF consultants) is also responsible for ensuring that the preparation and implementation of SS-ESMPs are in compliance with the Project’s ESMF and SEP taking into account the GOL regulations and the risks and mitigation measures identified in the ESMF including the relevant guidelines that are provided in Annexes III, IV, V, VI, and VII of the ESMF. PCO will also ensure adequate consultation with relevant key stakeholders and periodically report the implementation progress to the WB. 26. Given the urgency to increase COVID-19 treatment capacity, PCO has taken lead on Project budget allocation, procurement of equipment and supplies, and mobilization of consulting services. For the proposed new HCFs, PCO has signed a contract with a 12 consulting firm (PiSECCON) to complete detailed designs and supervise the construction of the three proposed HCFs, including preparation of the SS-ESMP for each of the new HCF. A consulting contract between PCO and PiSECCON for the above services was signed in April 2021 and PiSECCON has started the consulting service. 27. To ensure that construction can start in late January 2022, a direct contracting for 3 contractors (one contract for each HCF) has been applied. PCO – in close consultation with the technical departments of MOH, has led the mobilization of contractors for construction of the three proposed HCFs. 1.3. Objective and Scope of SS-ESMP 28. SS-ESMP objective. This document is a site-specific Environmental and Social Management Plan (SS-ESMP) for the construction of COVID-19 Treatment Health Care Facility (HCF) in Sekong Provincial Hospital (SPH) in Sekong Province (SP). The HCF construction is part of the Activity 2.5.2 of Component 2 to be implemented by Department of Healthcare and Rehabilitation (DHR) of MOH. The SS-ESMP aims to identify the E&S risks and impacts and mitigation measures of the proposed HCF (or SPH) taking into account (a) the results from the ES screening; (b) ESMF, SEP, and ESCP requirements; (c) review of the proposed design of the COVID-19 HCF; and (d) data collection on the general and site-specific E&S background and consultation with DHR, LA/LC, and other key stakeholders. 29. The PCO will be responsible for ensuring effective and timely implementation of the SS-ESMP both during construction and operations, including provision of budget for ensuring effective operations of the HCF of SPH for at least 2 years after construction is completed (mid of 2022 to end of 2023) as agreed with the Bank. As part of the project, technical assistance (TA) will be provided under Component 4 to strengthen capacity of the HCF owner to improve safe and effective management of medical wastes for the long run. The PCO will provide guidance, training, monitoring and evaluation, and reporting on the implementation progress to the WB. CHAPTER 2. DESCRIPTION OF PROJECT 2.1. General Description 30. The Project activities are being implemented by MOH technical departments under the leadership of the following 7 key agencies: Department of Healthcare and Rehabilitation (DHR), Department of Hygiene and Health Promotions (DHHP), Food and Drugs Department (FDD), National Center for Laboratory and Epidemiology (NCLE), National Center for Communication and Education for Health (CCEH), Department of Communication Disease and Control (DCDC), and provincial and district health offices (PHO and DHO). The Project Coordination Office (PCO) of Department of Planning and Cooperation (DPC) of MOH has been established to be responsible for overall coordination of Project implementation including facilitating full compliance with the ESF requirements described in the ESMF, SEP, and ESCP for the Project. 13 31. In coordination with other MOH technical agencies, DHR is responsible for planning and provide technical guidance to improve capacity (such as knowledge, facilities, and equipment) to ensure effective treatment and operations of all HCFs in Lao PDR including the proposed HCF. 32. Under this Project, in addition to construction of three new HCFs for COVID-19 treatment, DHR is also implementing other Project activities especially those identified under Components 1, 2, and 4 (see Box 2.1). To facilitate effective and timely planning and implementation of ESF requirements, DHR has assigned the ES focal point to work closely with PCO and other agencies. Box 2.1 Main activities being carried out by DHR Component 1 • Activity 1.2.1 (PPE and consumables for infection control) focuses on procurement of PPE and supplies while Activity 1.2.2 (Infection prevention and control training) of staff of the 7 central hospitals and 17 provincial hospitals. • Activity 1.5.1 to 1.5.4. focus on training and procurement of equipment related to case management and isolation while Activities 1.5.6 and 1.5.7 focuses on procurement of medicines and vehicles for DHR. • Activity 1.8.1 involves procurement of laboratory equipment related to essential health service delivery under DHR responsibility and sharing with NCLE covering large amount of budget ($2M) while Activity 1.9.1 covering overtime payment. Component 2 • Activity 2.1.1 to 2.1.4 involve development of COVID-19 guidelines development, patient management, Infection and Prevention Control (IPC), etc. for all central and provincial hospitals and training. • Activity 2.5.1, 2.5.2, and 2.5.3 involve setting up 3 new healthcare treatment facilities (HCFs) each consisting of an Intensive Care Unit (ICU), an isolation ward, and a laboratory, one in Phonthong district of Champasack province, one in provincial hospital in Attapeu province, and one in provincial hospital in Sekong province (Activity 2.5.2); and provision of medical equipment and supplies for management of the HCFs ( Activity 2.5.3). Under Activity 2.5.2, three new HCFs will be constructed with Project support in Champasack, Attapeu, and Sekong provinces. Component 4 • DHR is among the key agencies to actively participate in the implementation of the technical assistance (TA) to be implemented under Project Component 4. 2.2. Description of the Proposed HCF in Sekong Provincial Hospital 33. Project objective and activities. The proposed new HCF aims to provide safe and effective treatment for COVID-19 patients in existing Sekong Provincial Hospital (SPH). Main activities will include (i) demolition of existing old buildings and site clearance; (ii) construction of a new COVID-19 HCF comprising one ICU, one isolation ward, one medical laboratory, one waste storage area, and one laundry area, including excavation for septic tanks and other earth works, structure works (concrete and steel), and architectural work (brick linings, plastering, painting, ceilings and roofing); (iii) Mechanical, Electrical and Plumbing (MEP) works; (iv) air-conditioning (A/C) and ventilations; (v) water supply, toilets, drainage, and wastewater collection and treatment system (WWTS) as described in detailed design. Operations of the proposed HCF, including disposal of medical and infection wastes on-site and off-site, will be about 18 months until the Project closing date (end December 2023). The 14 proposed HCF has been designed for universal accessibility and all facilitated with handicap design elements. 34. Project location. Sekong Provincial Hospital (SPH) was first established in 1994 and was renovated during 2014-2015. The SPH is located in the Province city center in Mai Huameaung Village, Lamam District, Sekong Province. The total area of the SPH is about 2 ha. The SPH is located in the middle of residential and commercial areas (Figure 1). The existing SPH was built into 3 one-story buildings. It has a total of 59 rooms, of which 41 rooms are for in-patients. The SPH has 23 divisions, staffed with 149 doctors and nurses (107 are female). The hospital provides services to people who live in Sekong province. The SPH has been used for COVID-19 treatment center since the second wave of COVID-19 outbreak. Under this project, the HCF will be constructed within the SPH to enable SPH to respond to the increasing need for COVID-19 treatment. The new HCF will be built within the existing SPH premise and comprise of three new one-story buildings with an estimated area of 1,529m2 (See Box 2.1 for details). To make way for the new HCF, eight existing buildings of the SPH will be demolished (See existing layout in Figures 2, new building layout in 3, and design details in Annex 2A). 35. It is noted that a separate budget has been allocated for procurement of medical equipment, PPEs, consumable materials and supplies, and training of staff considered necessary for ensuring safe and effective operations of the proposed HCF. Discussion is on-going on procurement of an autoclave for sterilization of infectious waste; availability of PPEs, disinfection chemicals and consumable materials and training for staff and workers responsible for waste management; and allocation of budget for operations and maintenance at least 6 months after the end of the Project closing date (December 2023). Given limited capacity and available budget of the HCF owner and MOH technical departments, discussion on scope and terms of reference (TOR) for the TA to be implemented under Component 4 are also on-going and expected to be finalized March 2022. These inputs are considered critical for ensuring safe and effective operations of the proposed HCF. Figure 2 - Location of Sekong Provincial Hospital in Sekong Province 15 Box 2.1 Description of new HCF in Sekong Provincial Hospital Contract Civil Work Description Contract ➢ Design and construction of new buildings, will include 4 buildings: 2: Sekong • Building No 1: ICU, 6 beds Provincial • Building No 2: Isolation Ward, 16 beds Hospital • Building No 3: Laboratory. • Building No. 4: Waste Management ➢ Building No 1 will be connected to an existing hospital building through a roofed walkway. The ICU and Isolation Ward will have a total capacity of 22 beds. The surface area of the total four new buildings and walkways is 1,542 square meters. Figure 3 – Existing Plan 16 Figure 4 – Layout Plan and Green Area 36. The construction activity will consist of demolition of existing buildings, site clearance, earthworks, and structural work (concrete and steel), architectural work (brick linings, plastering, painting, ceilings and roofing), mechanical, electrical and plumbing (MEP) work (A/C, ventilations, plumbing pipes, drainpipes, electrical wires and appliances, water supply and sanitation, etc.). Details of these works are provided in the design in Annex 2. The construction of the new HCF will require use of construction materials and disposal of construction wastes and other spoils from site clearance and demolition of the existing buildings. It is estimated that the construction materials will include soil (excavated from borrow area) and sand of about 1,950m3. Construction wastes is estimated to be about 1,600 m3 and debris from demolition about 1,200 m3. 37. During construction of the HCF, supporting facilities such as contractor’s office and workers’ camp which will be set up and within the existing SPH (See tentative construction schedule in Figure 1 below). Table 1 Tentative Construction Plan Activities M3 M6 M9 M12 Site Mobilization Civil and Structure Architecture MEP Landscaping Equipment Installation and Fitting in Commissioning Note: Actual construction implementation schedule shall be updated according to the awarded contractor’s proposed schedule. 17 CHAPTER 3. NATIONAL LEGISLATIONS AND ESMF REQUIREMENTS 3.1. National Laws and Regulations 38. Key national laws and regulations provided in the ESMF have been considered during the preparation of this ESMP and they will also be applied during implementation of the proposed HCF in Sekong Provincial Hospital. The EIA regulation requires the preparation of an IEE and SS-ESMP for the proposed HCF. PCO has discussed the scope, timeframe, and process with PONRE to ensure that PONRE approval for SS- ESMP for this project and an Environmental Compliance Certificate (ECC) can be issued before construction activities for the new HCF commences. Initial discussion with PONRE suggested that an ECC for the proposed HCF will be issued by end of December 2021. 39. Application and compliance with other national regulations related to Environmental and Social Health and Safety (ESHS) especially those related to labor, sexual exploitation and abuse (SEA), sexual harassment (SH), violence against children (VAC), ethnic peoples, occupational health and safety (OHS), road safety, and other health and safety aspects including those on COVID-19 pandemic will also be observed during the implementation of the Project. 40. It noted that during 2017-2019, various regulations related to healthcare waste (HCW) management have been issued by the MOH. These regulations will be applied during the implementation of the Project, including the proposed HCF in Sekong Provincial Hospital. However, the regulations will be updated by the relevant technical departments of the MOH taking into account the implementation and experience with the COVID-19 pandemic in Lao PDR since 2020. 41. Key purposes and technical aspects of the relevant provisions are highlighted below: o Decision No. 1373, dated 23 November 2017, issued by the Ministry of Health regarding Healthcare Waste Management. This Decision sets forth regulations to ensure all health care facilities implement measures to protect patients, visitors to healthcare facilities, healthcare workers, waste handlers, the general public and the environment from risks associated with healthcare wastes. This Decision covers such technical aspects as i) Classification/categories of healthcare waste, waste container, color code, label and symbol; ii) Waste segregation, collection, transportation, storage period, storage place; iii) Healthcare waste disposal; iv) Origin and component survey, budget plan development, health promotion, and waste reduction; v) Healthcare waste management staff’s health and safety management; vi) Establishment of environmental health management committees in healthcare facilities –roles and rights, including monitoring and evaluation; and vii) Policy for good performance and measures against violations. o Decision No. 1667, dated 15 August 2018, issued by the MOH regarding environmental health and hygiene standard. This Decision describes measures that will be taken by healthcare facilities to ensure required hygiene measures are fully in place, including safety and prevention of risks related to contaminated sources from patients and medical equipment to ensure safety for personal health worker, patients, patient’s relatives, villagers surrounding health facilities, including environmental protection. The Decision also prescribes roles, rights and 18 responsibilities in implementation of environmental health and hygiene standard, including hygiene standards for HCF, monitoring and evaluation, and measures for violation including penalties. o Technical Guideline on Sharps Waste Management, issued on 15 December 2019 by the MOH to ensure disposal of sharp waste, including also used syringes and needles, are properly carried out in accordance with the law to avoid adverse impacts on environmental health and ensure safety for medical service facilities across the country. The Guideline also guides how the Health Governance and Nutrition Development Project (HGNDP), Department of Planning and Cooperation (DPC), and the Department of Hygiene and Health Promotion (DHHP) work together to guide relevant stakeholders to gain awareness and understanding how to properly implement these tasks to avoid potential negative impacts on environmental sanitation and health of the general public. 3.2. ESMF requirements and ES screening 42. In line with the ESMF requirements, PCO conducted an ES screening for the activities being implemented by DHR (DHR subproject). Discussion with the WB’s ESF team suggested that the risk for DHR subproject is rated “substantial” since the subproject activities will involve construction and operations of three new HCFs for COVID-19 treatment while the risks of each HCF is also rated “substantial” due to rapid transmission of COVID-19 contagion in neighboring countries and worldwide, limited capacity and budget of the HCF owner and MOH agencies, and limited waste management capacity in Lao PDR. 43. To reduce the risk and impact to socio and environment. The SS-ESMP is developed for each of the proposed HCFs. This SS-ESMP describes specific measures to mitigate the potential ES risks of the proposed HCF both during construction and operational phases, the implementation and monitoring arrangements, consultation, grievance redress mechanism (GRM), and budget allocation. The SS-ESMP was also consulted with the local authorities, local communities, and other key stakeholders in a manner acceptable to WB, and it is expected that this SS-ESMP shall be endorsed by relevant authorities by December 2021 before the construction work commences. 44. Annex 3 presents the ES screening results for the proposed HCF to be constructed in SPH in Sekong Province while Chapter 5 describes the risks and proposes mitigation measures during the construction phase and operational phase. Key ES risks and impacts during construction phase are mainly associated with civil works activities including generation of construction waste, dust, noise, vibration, community health and safety (CHS), and occupational health and safety (OHS) as well as traffic safety for project workers and the general public during the transport of construction materials and equipment – both at the construction site within Sekong Provincial Hospital and outside the construction site. The risks and proposed mitigation measures are discussed in Chapter 5 and Annex 5. 45. Key ES risks during operations would include risks related to potential infection, waste management, and limited capacity and budget of the HCF owners to ensure safe and effective operations of the proposed HCF. These risks and the proposed mitigation measures have been identified and they are being discussed with PCO and MOH 19 technical agencies in light of the discussion on the scope of the technical assistance (TA) to be implemented under Component 4 of the Project. The risks and proposed mitigation measures are discussed in Chapter 5 and Annex 6. Chapter 5 describes the risks and propose mitigation measures during construction phase and operational phase while Annexes 5A and 5B provide more details on issues and mitigation measures during construction phase (referred to as C-ESMP) and Annexes 6A and 6B provide those related to operation phase (referred to as O-ESMP). 46. In parallel to the preparation of this SS-ESMP, PCO also initiated discussion with the Provincial Office of Natural Resources and Environment (PONRE) who is responsible for issuance of an Environmental Compliance Certificate (ECC) for the proposed HCF. A report (in Lao language) on description of the proposed HCF and mitigation measures to be conducted during construction and operations phases was submitted with an agreement that the SS-ESMP approved by WB will be sent to PONRE for their clearance and records. The ECC for the proposed HCF will be issued prior to commencement of construction activities. It is expected the project will obtain an ECC by the end of December 2021. CHAPTER 4. ENVIRONMENTAL AND SOCIAL CONDITIONS 4.1 Social Overview 47. Sekong province is located in southern Laos. The province is bordered by Vietnam to the east, Champasack Province to the west, Salavanh Province to the north, and Attapeu Province to the south. Sekong is best known for the Bolaven Plateau which is situated in the heart of the southeastern part of Laos. Sekong Province is the second smallest province of Laos and is also one of the poorest provinces. The province has an area of 7,665 km2 with a population of 113,048 people (2015) – province with smallest population and lowest population density. Sekong province is characterized by rugged terrain, wild and very beautiful landscape. Transportation is very difficult, especially by land during rainy season. In villages and small towns such as Lave, Lanam, Kaleum, Dakchung and Thateng, most people still adopt tradtional lifestyle and farming. Its complex geographical conditions form colorful Eco-Tourism resources, due to its abundance of untouched tropical forests, home to many rare species of flora and fauna. 48. Sekong has four districts, including Lanam, Kaleum, Dakcheung and Thateng. Sekong Province is one of the least explored provinces in Laos due to the rugged landscape and mountainous terrain that rises to the Dakcheung Plateau. With 14 distinct ethnic groups belonging to Mon-Khmer linguistic family, this sparsely populated province is probably most diverse, ethnically, in southern Laos. Katu and Talieng are the largest ethnic groups in the province and are noted for their unique religious practices that mix animism and ancestor worship2 (See more information, including maps and photo of the province, and the environmental condition of the proposed HCF in Annex 4). 49. The proposed HCF subproject is located in Mai Huameaung Village, Lamam District – the Province City Center). Lao Tai (majority Lao) is largest ethnic group in this district. 2 https://www.tourismlaos.org/southern-provinces/Sekong-province/ 20 This district is home to some individuals and households of Mon-Kher group who is considered as Indigenous People. These ethnic minorities have been mainstreamed into the Lao Tai villages. The majority of Lao Tai and Mon-Khmer believes in Buddhism. People can access to public services, education and healthcare system. Most adult people, including the minority Mone-Khmer people who live in Lamam District, can read, write and speak Lao as the official language. The economic output of the district consists primarily of agricultural products especially production of coffee and tea. Sekong Province is one of the most important coffee-producing areas of Laos. 50. All households in the district have access to the basic services such as infrastructure, water and electricity. Sanitation and hygiene condition of most households are good. Although not all households have access to piped water supply, they still have enough clean water collected from borehole and dug well for daily living activities. Foods and other household supplies can be bought from many small shops nearby. 51. People usually go to Sekong Provincial Hospital for medical care. Some people buy medicine at the pharmacy to take by themselves. Also, some people still practice traditional healing method and seek assistance from folk healers and take native medicine as an option for their illness treatment. People can access to Covid-19 information from online media such as Facebook. As of July 2021, about 14,556 people in Sekong Province have received first dose of COVID-19 vaccine. As up to 3rd December 2021. Sekong province has 462 case got infected by COVID-19 in total (341 people has been recovered) with zero death case. 4.2 Environmental Overview (a) Healthcare Waste Management (HCWM) 52. Medical waste is a mixture of sharp objects such as needles, blood, body parts, chemicals, pharmaceuticals, and medical devices which may contain harmful components. Operations of these medical facilities will increase generation of medical wastes, including healthcare waste contaminated with COVID-19. Safe and effective on-site management of medical wastes (separation, collection, treatment, and disposal), including transportation and disposal off-site is of great concern. Infectious and biohazard waste will be generated from labs, ICU, and isolation wards, including liquid contaminated waste (e.g. blood, other body fluids, and contaminated fluid) and infected materials (water used; lab solutions and reagents, syringes, bed sheets etc.). Effective and safe management of these wastes will require enhanced capacity of HCF staff, including training for truck drivers and landfill-workers. 53. For the proposed HCF in Sekong Provincial Hospital, currently solid waste generated during the HCF operation is segregated into infectious, sharp wastes, and non- hazardous wastes. It is estimated the SPH generates approximately 40-80kg/day (infectious wastes: 5kg/day, sharp wastes: 5kg/day and non-hazardous wastes: 80kg/day). With an expanded COVID-19 treatment services (from existing 8 beds to 30 beds), it is expected that about 375 kg/day of waste will be generated. However, specific amount for each type of wastes (infection, sharp, general, etc.) cannot be estimated. Some data suggested that infection wastes can be about 10% of the total 21 wastes. More information on HCWM in the proposed HCF is provided in Annex 6A. As per the WHO guideline, the new COVID-19 treatment facility expects to generate the infectious waste estimated at 3.4kg/person/day during the high pandemic period and 0.5kg/person/day during low period. At SPH, there is currently one autoclave with capacity of 18 kg (in good condition) and one low temperature incinerator which is no longer in use due to air pollution concerns (See photos of existing conditions of the HCF in SHP and the provincial landfill in Annex 4). 54. The existing waste disposal system in use at SPH includes (i) a small incinerator (low temperature) for burning sharp wastes; (ii) autoclaving for infectious waste (prior to being disposed together with non-hazardous waste at provincial landfill located 9.5 km outside the city (See Figure 5). There are four autoclaves (3 are working properly). The provincial landfill was not properly constructed – there is no lining, leachate and drainage system in place. The healthcare waste is not properly managed and disposed (opening and dumping) due to the lack of standardized incinerators, autoclaving and lack of budget to construct a sanitary landfill. The management of healthcare waste requires attention and diligence to avoid adverse health impact associated with the existing inappropriate practices which increase public exposure to infectious agents and toxic substances. Figure 5 - Location of Landfill (b) Healthcare Wastewater Treatment System (WWTS) 55. Review of documents suggested that in Lao PDR, operations of healthcare wastewater treatment plant in existing hospitals and/or HCFs are lagging and those available in 1- 2 hospitals (which were constructed as part of assistance from international agencies (such as UNICEF, JICA, etc.) are not in operation and in need of repair. The existing operating wastewater treatment is basic septic tanks with brick lining, gravel, sand, and ordinary charcoal provided for each building toilet system. DHHP is now assessing the wastewater treatment system of existing facilities that are providing treatment service 22 to COVID-19 patients. This will be their priority to improve and rehabilitate existing wastewater treatment system to meet the quality water discharge of GoL and WHO. 56. Severe Acute Respiratory Infections (SARI) Treatment Centre. Based on previous field experiences and available reference extrapolations, the following daily estimate tools are recommended for a SARI treatment center: • 250 litres/staff member7/day + 2 days backup • 100–200 litres/bed capacity/day + 2 days backup. • Aim for the higher values first and readjust if needed. (c) Topography and climate 57. Sekong Province, Lamam District, generally has some mountainous terrain distributed in the district as shown in the map below, at elevations ranging between 100-1266 m ASL, the detailed topographical survey has been conducted at the project site with the elevations ranges from about 132.8 – 137.8 m ASL and all most area of the site is in gently plains terrain with some declining slopes toward the west of the project site. The elevation contours are illustrated in the figures below. 58. The climate conditions in the southern part of Laos can be summarized as follows: For the monthly average rainfall amount in Salavan, Champasack, Sekong and Attapeu Provinces, it can be observed that there is rainfall in the whole period of the year, but more active from May to September. During the dry season, there is less rainfall such as during January – March and October – December when rainfall ranges 0.0 mm to 165.6 mm. Zero rainfall record was found in Soukkhouma during January. While from April to September, rainfall ranges from 73.7 mm to 495.6 mm, especially in July and August when the average rainfall amount observed are 308.1 millimeters per month. 59. For the daily maximum rainfall in 24 hours in Salavan, Champasack, Sekong and Attapeu Provinces, it can be observed that the highest maximum rainfall amount in 24 hours was about 450.2 mm recorded in Pakse in June, the second highest was about 400 mm in September recorded in Attapeu. The monthly number of raindays in Northeastern part. Maximum number of rainy days occur more frequently in July and August. 60. The monthly extreme minimum and maximum temperature in Salavan, Champasack, Sekong and Attapeu Provinces, respectively. The lowest temperature occurs more frequently in January, February and December. The lowest monthly min temperature was recorded at 5.5 C in January in Sekong, and the highest max temperature was recorded at 42 C in Saravanh in May (See charts in Annex 4 – Section C). (d) Flooding 61. Flooding. The majority of the population lives in the plains or hilly areas (stretching from the Mekong River or its tributaries) are directly and greatly affected by floods or flash floods caused by heavy rain due to southwest monsoon or typhoon/tropical depression from the South China Sea. However, Lao PDR lacks the funds and the adequate technology to manage these abundant water resources and the country is affected by floods almost every year. This leads to significant stagnation of the social and economic development. In particular, during the rainy season from May to September, great amount of rainwater flows from mountainous areas into tributary, then to the Mekong River. As a result, during the rainy season, water discharge into the 23 Mekong River increases to 80%-90% and the water level is 10 m higher than that during dry season, causing inundation in the plains and flood in the Mekong delta. 62. For Sekong Provincial Hospital, based on the map of flood risk model, it appears that Sekong Provincial Hospital is not subject to flooding because of water rise from river. However, heavy, and prolonged rain, if any, may result in temporary, localized flooding. The design consideration of the proposed facilities have taken into account this flood risk (See Map of Flood Risk in Annex 4 – Section C). (e) UXO 63. PiSECCON obtained the NRA’s UXO contamination data in Sekong Province. The preliminary screening for the UXO risk for the project site is shown to be from medium to high risk as the map shows that there are some records of the munition in the proximity of the project. Due to the urgency and uncertainty of the risk, a technical survey for UXO screening will be included as the preliminary work scope of the contractor (See Map of UXO Risk in Annex 4 – Section C). CHAPTER 5. RISKS, IMPACTS, AND MITIGATION MEASURES 64. This chapter describes potential risks, impacts, and proposed mitigation measures for the proposed HCF during its construction and operation stages. The risks and impacts associated with the proposed new HCF in SPH were identified based on (a) the ES risk screening for the proposed HCF described in Chapter 3 and Annex 3; (b) the scope and nature of the civil works and future operations of the new HCF (for the purpose of COVID-19 treatment); (c) potential risks and impacts as anticipated in Project’s ESMF (particularly Annexes III, IV, V, and VI); (d) GOL regulations and the on-going consultation with the technical departments within and outside the MOH and the World Health Organization (WHO) in Lao PDR; and (e) consultation with local people and local authorities in Lamam District, Sekong Province. 5.1 Risks and Impacts and Mitigation Measures during Construction Stage 65. Construction will be made inside the existing premise of the SPH, no land acquisition and/or physical resettlement will be required. The civil works associated with the new HCF includes demolition of 8 existing buildings, construction of 4 new buildings, and installation of necessary equipment and technical facilities to ensure safe and effective management of solid and liquid wastes, including infectious, pathological, sharps waste, etc. 66. Key ES risks identified during construction include those related to (a) demolition, excavation, and construction works which will mainly involve safety of workers, HCF patients and visitors, and local communities including those related to UXO; (b) generation of noise, vibration, air/dust, and water pollution, and wastes (construction and general); (c) traffic management and road safety; and (d) social risks related to labor management, sexual exploitation and abuse (SEA), sexual harassment (SH), and violence against children (VAC), and vulnerable ethnic group. In light of COVID-19 pandemic, there are also risks related to potential transmission of COVID-19 contagion among contractor staff and workers; HCF staff, patients, and visitors; and staff of local authorities and local peoples due to inadequate/ineffective prevention and control of 24 infections (wearing masks, hand washing, social distancing, etc.) as well as possible transmission associated with procurement of goods and supplies and training activities to be conducted by contractor, suppliers, and other individual. Details are provided in Annex 5 and its 4 attachments. 67. Due to the COVID-19 outbreak which restrict social gatherings, and the small scale of works (one-story buildings) which does not involve a large number of workers and high level of technical skills, local contractors and suppliers are likely to be engaged to carry out the civil works. Given this, labor influx from neighboring countries, and other provinces in Lao PDR, is unlikely. However, since skilled labors may not be available in the project area, these workers may have to be mobilized from other districts and/or provinces. As a result, there are potential risks related to community health, such as increased risks of contracting communicable diseases such as COVID-19, and non- communicable diseases for community members, including traffic safety and risks related to sexual exploitation and abuse (SEA), sexual harassment (SH), and violence against children (VAC), and other social issues such as conflicts with local people, petty crime, etc.) as a result of labor force involved in construction of the proposed PCF. 68. Construction of the proposed HCF will involve demolition of old buildings inside the SPH, site clearance, construction of new one-story buildings, establishment of workers’ camp inside the existing SPH, transport of construction debris, materials, and waste between SPH premise and other sites, such as landfill. Potential key risks and impacts include: a) Environmental impacts as a result of physical construction (demolishment, building) such as noise, dust and vibration; b) Occupational health and safety (OHS) for workers during construction, transportation and disposal of debris and construction waste; c) Community health and safety (CHS) due to increased risks of contracting of communicable and non-communicable diseases, such as COVID-19, for patients, hospital visitors, healthcare professional and workers, and community members, safety related to construction activities, and traffic safety, etc. It is noted that during construction of the new HCF, other existing departments of the SPH (which are in other separate buildings) are still operational as usual); d) SEA/SH/VAC due to labor influx; e) Potential risks for local ethnic groups; f) Potential risk and impacts related to CHS due to procurement, delivery, and transportation of goods, services, supplies, and construction materials; g) Traffic accidents; h) Unexploded Ordnance (UXO); and i) Risks related to Life and Fire Safety. 69. Risks and impacts related to environment. Impacts related to dust, noise, vibration, construction wastes3, solid waste and safety issues are assessed to be small, localized, and short-term. These impacts, therefore, can be managed through preparation and implementation of good demolition plan and adoption of good construction practices. To mitigate these risks and impacts, the contractor will be required to take necessary measures during construction to avoid/minimize the identified risks and impacts. 3 It is noted that ACM, which is present in old zinc roof, is the only hazardous material during demolition process. 25 PiSECCON has been engaged by PCO to support PCO in the process of designing the new HCF, drafting contract document (CD), and preparing the SS-ESMP for the proposed HCF. PiSECCON will be also responsible for supervision of construction in the role of PCO’s CSC. 70. At this stage, the ES obligations (ESO) to be implemented by the contractor as described in Annex 5 Part B and its 4 attachments has been incorporated into the CD and construction is expected in November 2021. The proposed mitigation measures include those related to: (1) infection prevention and control of COVID-19 including preparation of a COVID-19 response plan as suggested by the Project ESMF; (2) Labor management and worker social code of conduct while will require the signing by contractor staff and workers (SCOC); (3) Communication and stakeholder engagement action plan to ensure effective and timely coordination between Contractor and the HCF manager, local authorities, and local communities; (4) Site clearance and safety plan to address risks related site clearance and earth excavation including those related to UXO and safety of the HCF’s patients and visitors during construction; (5) Demolition of existing buildings plan to avoid issues during demolition; (6) Waste and worker camp management aiming to address OHS of workers at all work sites and in the worker camp as well as those measures to address safety of local communities located near the construction site; (7) Construction management and pollution control aiming to avoid/reduce air/noise, vibration, and waste generation, including an Emergency Preparedness and Response plan in case of accidents and/or injury of Contractor’s staff and workers occur; (8) OHS and CHS plan to address health and safety issues; and (9) Transportation and road safety management aiming to reduce the risks related to transportation of construction materials and disposal of spoil and construction wastes. Key specific risks and proposed mitigation measures are discussed below. 71. Risks related to occupational health and safety (OHS) for workers. OHS risks may relate to accidents (for workers) while working at construction sites, and OHS risks of contracting communicable and non- communicable diseases on the part of workers and local community members. Given the high possibility of engaging more local workers for the civil workers, the risks related to occupational health and safety (OHS) for local workers may increase because local workers may have limited knowledge and experience about OHS requirements. When living in workers’ camp, small living space and temporary living conditions in the workers’ camps may increase the risks of transmission of communicable disease among workers and between workers and those with whom the workers interact (e.g. local workers with their family members). Thus, adequate training for the contractor and their workers 4 about OHS and COVID-19 infection prevention and control, and waste management procedures as well as awareness raising for the HCF’s staff and workers and for local community nearby the HCF, are vital to keep these potential risks low. 72. Risks related to SEA/SH. These risks are related to the influx of labor who are engaged under the project by the Contractors to carry out construction of the HCF. To minimize the possibility of engaging workers from other localities, a qualified national firm will be engaged as construction contractor through a direct contract process. Contractors will 4 Temporary workers camp will be set up inside the hospital premise but will be separate and located inside the construction site which be protected with surrounding fence. Workers’ camp will established in accordance with the environmental and social mitigation measures set out in Table A5.1 of Annex 5. 26 be encouraged to recruit local people, which is highly feasible in this case because of the small scope of civil work for the proposed HCF in SPH and the current travel restriction due to COVID-19 which may discourage contractor from mobilizing their usual workers from other localities. During the preparation of this SS-ESMP and before construction takes place, PiSECCON has conducted consultation with local people and local authorities to raise the awareness of local people about these risks and to solicit local suggestions about measures that can be taken to avoid/minimize the risks. The Project’s Redress Grievance Mechanism (GRM) was also presented to the community to show them , therefore, they were aware how they can to access to this Project’s GRM when needed during the construction and operation of the HCF. Project’s GRM will also be disclosed locally at the construction site, Sekong Provincial Hospital, and locally at communes nearby the SPH for public awareness and use when needed. The result of consultation is included in Annex 8 of this SS-ESMP. PiSECCON will also provide training for workers to raise awareness of SEA/SH risks and in compliance with the ESCOP, Social COC, LMP, and SEP. This aims to ensure these risks and potential impacts can be avoided, or minimized through effective application of the contractor, their workers, community workers (such as community health volunteers), etc. during construction. The performance of the Contractors on the ES requirements will monitor and managed (see Chapters 6, 7, 8 and 9). 73. CHS risks for people in SPH and community. The construction of the proposed HCF located in SPH may increase the risks related to CHS for those who are present in the SPH premise, including health professional, health workers, project workers, patients and visitors. Patients, visitors and local communities nearby the construction sites may be exposed to increased health risks during the construction due increased level of dust, noise, vibration, and disturbance caused by the operation of construction equipment and machines, transportation of construction materials and increased safety risks such as traffic accidents associated with above construction activities. These are classified as moderate risk. Both health professionals and communities could be also exposed to risks associated with the labor influx, and risks of contracting communicable diseases such as air-, waste- and water-borne diseases, including COVID-19. During demolition of old buildings and construction of new buildings, existing HCF will remain in operations. However, the safety risk for building users, indoor patients, and surrounding communities is considered moderate and the contractor is required to install temporary safety fence and warning sign around the new construction sites as required by PiSECCON and this is included in the contract (see Annex 5)5. The old buildings to be demolished and the new construction sites will be fully separated from existing buildings. 74. To ensure mitigation measures for these risks/impacts are consistently and effectively implemented by the Contractor, all mitigation measures have been incorporated into Annex 5. Specific requirements are summarized in Table A5.2 and 4 attachments that have been incorporated into the contract documents (CD) as part of Contractor’s ES obligations. Before construction begins, the contractor will be required to install 5 PiSECCON suggested that according to the design, a fence of 2.5m high with zinc sheet will be installed between the construction sites and existing buildings. 27 temporary fences with appropriate warning signs and light signals. This is to prevent people such as building users, indoor patients, community member, etc. from entering the construction site. Works will be limited to daytime working hours while regular watering will be used to prevent dust generation as agree with HCF owners. Contractors will train their workers to make sure all workers are aware of Environmental, Social, Health and Safety procedures (ESHS). The contractor will also be required to comply with national environmental quality standards as well as to maintain close consultation with the HCF owner, local authorities, including local police and local communities on demolition, construction plan, and identification and arrangement for appropriate sites for disposal of all construction debris and wastes. In Lao PDR, use of asbestos contaminated material for ceiling and building walls for the old building that were constructed in the past are considered possible. Before demolition of existing buildings is allowed, PiSECCON will investigate for the presence of asbestos contaminated materials (ACM), and if found will ensure that removal of the ACM by contractor will follow the WB protocol on ACM6. 75. and apply the control and disposal measures as provided in Annex 5 during the demolition and construction. PiSECCON will also ensure that the plan is disclosed for consultation and agreement with local authorities and local communities. The contractors will be responsible for providing adequate PPEs and training their workers to perform their tasks safely and effectively, including ensuring full compliance with procedures for COVID-19 prevention and control. Disposal of the construction wastes will be made according to agreement with local authorities, such as PONRE, etc. 76. Potential risks for local ethnic groups. There are some individual members of ethnic groups and ethnic households living together with the mainstream ethnic group in the vicinity of the proposed construction sites and along the roads that are used to transport construction materials, debris and wastes. Risks due to workers coming from infected areas and/or co-workers becoming infected including workers introducing infection into community/ general public, including risk of Covid-19 transmission. Potential risks and impacts on these ethnic households can be managed through consultation with potential affected groups in the project area and in accordance with the SEP and this SS-ESMP. An inclusive and consultative process, described in the SEP, will be applied to ensure the ethnic individuals and households are well informed of the construction activities for the HCF, and its associated risks and impacts (both positive and adverse) inside and outside the HCF, and measures that have been in place to manage such risks and impacts. The public consultation was conducted by PiSECCON in October 2021 and all suggestion getting from communities and local authorities have been incorporated into this SS-ESMP and in the Annex 8. In addition, The SEP and the participatory process will also ensure these ethnic people, as well as other disadvantaged/vulnerable groups, will be able to access and benefit from the new COVID-19 treatment facilities in manner that is culturally appropriate to them Concrete measures to ensure access and benefit for ethnic people from the HCF’s services include allocation of ethnic health workers or 6 http://www.mtpinnacle.com/pdfs/AsbestosGuidanceNoteFinal.pdf 28 well-trained ethnic volunteers to help with communication in the HCF and use of reader- friendly IEC materials produced by WHO, UNICEF and MOH for awareness raising. 77. Potential risks related to CHS due to procurement, delivery, and transportation of goods, services, supplies, and construction materials. Delivery of construction materials, goods, and services by contractor may increase the risks of transmission of COVID-19 if appropriate measures are not in place and implemented. Imported materials may be contaminated and handling of the goods during transportation may increase the risk of spreading of diseases if PPE such as face-mask, hand washing and social distancing is not applied appropriately. Inadequate hand washing facilities while transporting goods and wastes generated from imported goods and transportation activities could increase the risk of contracting/spreading of diseases. The Contractor has been required to carefully plan and implement specific measures for delivery of goods and services according to the IPC described in the CD and GOL regulations. 78. Traffic accidents. Traffic accidents may happen during the transportation of goods, construction materials, construction waste, debris and healthcare waste. This risk can be reduced through provision of training to drivers on safe driving practices Potential risks of accidents associated with borrow pits and disposal of construction wastes, spoil and healthcare waste include accidents (e.g. due to landslide). These risks will be mitigated through the application of the environmental code of practices and through consultation with local authorities and communities. 79. Unexploded Ordnance (UXO). The risk related to UXO due to construction activities of the new HCF is considered to be low (see map in Annex 4) because the location of the new HCF is within the existing district hospital and deep excavation is not expected due to the construction of one story-building is not needed the deep excavation and deep foundation. PiSECCON has collected relevant information and assessed that the potential risk of UXO is low. However, a small budget has been allocated in the contract for the contractor to take a technical UXO survey at the proposed site. PCO and PiSECCON will also discuss with the national regulatory agency (NRA) for the clearance certificate, as needed. 80. Life and Fire Safety (L&FS). Given the nature and size of activities to be conducted for the proposed HCF, risks concerning Life and Fire Safety are considered moderate during construction. The contractor is required in the CD to prepare an emergency preparedness and response plan during construction. Potential impacts related to use of security personnel is not expected since this service is not planned at this stage. If this service is considered necessary at a later stage, a Security Risk Assessment (SRA) will be conducted and action plan will be prepared and submitted to the WB for review prior to engagement of security personnel. For safe use of oxygen for patients, nurse will be retrained for safe administration of oxygen to COVID-19 patients, particularly when used for vulnerable patients such as premature infants and those with chronic obstructive pulmonary disease. To minimize the risk of fire due to oxygen, fire extinguishers shall be installed at appropriate places inside buildings with oxygen tanks. Fire prevention standard of MOH shall be applied (See Annex 3C. Box 2). 29 81. Other construction risks, such as fuel storage and refueling, cement processing, storage of any chemicals or hazardous materials, etc. (See details in Table 52.A in Annex 5). 5.2 Risks, Impacts, and Mitigation measures during Operational Stage 82. Occupational Health and Safety risk management measures: Operations of the proposed Sekong Provincial Hospital will begin soon after the construction and site closure are completed and this is expected in mid-2022. The HCF owner will be responsible for ensuring effective and safe operations of the HCF. Effective mitigation measures and adequate capacity and budget of the HCF owner to address the risks/impacts associated with the operations of these new facilities will thus be critical, especially with the potential increased in spreading of communicable diseases such as COVID-19 from potential increased number of patients and waste, and the capacity constraint of health workers’ capacity to address the increased risks of COVID-19. The risks related to OHS for health personnel, workers, and to the general public can be reduced by enhancing the capacity of the HCF owner with regards to healthcare waste management, improved construction design (compatible with COVID-19 treatment), and effective HCF operations procedures. Appropriate use of personal protection equipment (PPEs) and disinfection equipment, chemicals, and other materials is also essential to effective and safe operation of the new HCF and standardized COVID-19 prevention protocols, such as social distancing, hand washing, wearing of masks, vaccination, etc. will be applied. Detailed discussion had been conducted with the WB technical and ESF teams on safety aspects related to building layout, heating- ventilation, air-conditioning (HVAC), and solid/liquid waste management, especially those related to medical/infection wastes. 83. CHS risk management measures: Given the current limited financial resources and capacity of the healthcare staff in providing treatment to an increasing number of patients, including patients returning from neighboring countries as migrant workers, increased risks identified during HCF operations include, but not limited to, spreading of infectious and communicable diseases such as flu, HIV/AIDS, sexually transmitted infections, etc. due to labor influx, and transmission of diseases among patients, between patients and healthcare professionals/workers, and patients and surrounding communities. This is due to the increased amount of and exposure to healthcare wastes, wastewater, and toxic/hazardous/chemical wastes, including waste from laboratory activities (biosafety category A) that are to be generated during the operation of the new HCF. The impacts on community health and safety may increase, especially under the impact of natural disaster and climate change impact such as flooding. As such, building capacity for the HCF owner for emergency response is essential and will be part of the technical assistance implemented under Component 4 (see Section 5.3 below). Also, to ensure ethnic minority people can access to and benefit from the new HCF’s services, PDH will ensure ethnic minority health workers or well-trained ethnic minority volunteers are arranged at the HCF to assist EM patients/visitors for effective communication with HCF staff. In addition to support in verbal communication, Information, Education, Communication (IEC) materials produced by WHO, UNICEF 30 and MOH for awareness raising in COVID-19 prevention and treatment will be translated into EM languages of the major EM groups in the area. `5.2.1 Healthcare Waste Management (HCWM) 84. Risks and Potential impacts from the health care wastes (HCW) during the HCF operations. The proposed HCFs will comprise ICU, isolation ward, and laboratory. Operations of these medical facilities will increase generation of medical wastes, including healthcare waste contaminated with COVID-19. Safe and effective on-site management of medical wastes (separation, collection, treatment, and disposal), including transportation and disposal off-site is of great concern. Infectious and biohazard waste will be generated from the proposed laboratory, ICU, and isolation wards, including liquid contaminated waste (e.g. blood, other body fluids, and contaminated fluid) and infected materials (water used; lab solutions and reagents, syringes, bed sheets masks, gloves, patient and staff gowns, ventilator and other equipment waste, vials, spent medication etc). Effective and safe management of these wastes will require enhanced capacity of HCF staff, including training for truck drivers and landfill workers. 85. As discussed in the Project ESMF that healthcare waste contains potentially harmful microorganisms that can infect hospital patients, health workers and the general public. Other potential hazards may include drug-resistant microorganisms which spread from health facilities into the environment. Adverse health outcomes associated with health care waste and by-products also include7: sharps-inflicted injuries; toxic exposure to pharmaceutical products, in particular, antibiotics and cytotoxic drugs that are released into the surrounding environment, and to substances such as mercury (e.g. in broken thermometers), or dioxins, during the handling or incineration of health care wastes; chemical burns arising in the context of disinfection, sterilization or waste treatment activities can cause air pollution. Thermal injuries occurring in conjunction with open burning and the operation of medical waste incinerators; and radiation burns (caused by products contaminated by radionuclides such as radioactive diagnostic material or radiotherapeutic materials) are hazardous. Effective SOP and provision of appropriate PPEs and training to profession staff and workers to handle, temporary storage and disposal these wastes will be important and should be part of the capacity building effort to be carried out under Component 4 (see below). 86. Treatment and disposal of healthcare waste may also pose health risks indirectly through the release of pathogens and toxic pollutants into the environment. The disposal of untreated health care wastes in landfills can lead to the contamination of drinking, surface, and ground waters if those landfills are not properly constructed. The treatment of health care wastes with chemical disinfectants can result in the release of chemical substances into the environment if those substances are not handled, stored and disposed in an environmentally sound manner. Incineration of waste has been practiced, but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air and in the generation of ash residue. Open burning of waste is not acceptable as burning at low temperature can generate dioxins and furans, 7 https://www.who.int/news-room/fact-sheets/detail/health-care-waste 31 which are human carcinogens and have been associated with a range of adverse health effects and high particulate matter e.g. plastic. Incineration of heavy metals or materials with high metal content (in particular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment. Only modern incinerators operating at 850- 1,100 °C and fitted with special gas-cleaning equipment are able to comply with the international emission standards for dioxins and furans. 87. Alternatives to incineration, other treatment options such as autoclaving, microwaving, steam treatment integrated with internal mixing, which minimize the formation and release of chemicals or hazardous emissions will be considered in situation where resources are sufficient to operate and maintain such systems before disposal of the treated waste at the provincial landfill. Treatment of infection waste with disinfection chemicals (chlorine or other chemicals) before transportation to the off-site final disposal can be acceptable only when the offsite landfill disposal and management is acceptable (sanitary or specialized cell/location for HCW). However, despite of their advantages, autoclave, incinerators, and also microwave have their shortcomings. An autoclave is powered by electricity. As a result, it reduces the need for fossil fuels, which contributes to environment protection. However, the level of electricity required to operate the sterilization process of an autoclave is considerable which reduces the benefits of being ‘Carbon Neutral’. It also required well trained staff to operate. Incinerators face a negative press due to the perceived negative effects of burning waste. Common concern about incineration is that its operation creates smoke and odors. However, selection of right incinerators can lesson this problem (through technology that uses secondary chamber that heats the gasses to more than 1,100ºC and releases only clean gasses back into the environment. Compared to traditional autoclave solutions, which consume high amount of energy, microwave sterilization solutions minimize the significant risks of pressure thanks to their ease of use by unqualified operators. Their maintenance is simple and low cost compared to competing technologies associated with autoclave and incineration. 88. Technical discussion on detailed design of the proposed HCF suggested for procurement of additional autoclaves for sterilization of infectious wastes before final disposal as well as having adequate PPEs, consumable chemicals and supplies, training of staff and workers, technical assistance, and budget allocation of the proposed HCF. This is to ensure safe and effective operations of the proposed HCF when construction is completed. The HCF owner and relevant agencies will be responsible for taking actions to mitigate the environmental and social risks and management during construction and operations of the proposed HCFs. Merits and deficiencies of existing technologies, especially between autoclave and microwave, in the context of Lao PDR were discussed extensively. 89. Lack of awareness about the health hazards related to health-care waste, inadequate training in proper waste management, absence of waste management and disposal systems, insufficient financial and human resources and the low priority given to the topic are the most common problems connected with health-care waste. These issues have been considered during the preparation of this SS-ESMP and appropriate 32 measures8 will be identified as part of the TOR for the Technical Assistance to be implemented under Component 4. 90. Proposed mitigation measures for operations. To mitigate the potential risks and impacts during operations of the proposed HCF discussed above, at this stage, it is considered that application of the on-site autoclave or microwave is appropriate. However, cost complication is being considered. Operational experience suggested that the autoclave should be operated by qualified staff and that water use needs to meet a specified standard. Fluctuation of electrical voltage can affect effective operations of the machine. Microwave seems more attractive, but investment cost is high, including high-cost maintenance (e.g. expensive spare parts). Given the existing limited capacity as well as WHO recommendations, PCO and MOH technical agencies decided to procure more autoclaves and provide more training and capacity building to the HCF owner and staff and the activities will be implemented before construction is completed. Training will cover also effective use and maintenance of on-site waste treatment by using autoclave, as well as transport and disposal of medical wastes. The current provincial dumpsite will be used for disposal of treated medical waste without redesigning it. However, a technical assistance is being discussed to address issues related to proper arrangement of landfill site and disposal of infectious waste in the southern part of the country including the one for Sekong province. 91. PCO has been working with MOH technical departments (DHR, DHHP, NCLE), the HCF owner, and the WB team to ensure that appropriate equipment, training, TA, and budget are provided to facilitate safe and effective operations of the proposed HCF. Table A6.1 in Annex 6 identified key risks and proposed mitigation measures to be implemented during operations and discussions are on-going, taking into account MOH regulations and the guidelines identified in the ESMP. It is expected that in early 2022, the TA to be implemented under Component 4 will provide technical support to the HCF staff to ensure that operations of the proposed HCF will be effective. 92. PCO will also facilitate the discussion with DHR and DHHP to turn this SS-ESMP into MOH regulations, technical guideline, and/or Standard Operational Procedures (SOP) on HCW management procedures for application in other COVID-19 hospital in Laos. Improvement of capacity building of HCF owners, MOH’s technical department should be considered. During the planning process, PCO will ensure that the HCWM approach to be applied for the proposed HCFs, including those to be applied under the WASH 8 According to WHO, the key elements in improving health-care waste management are: promoting practices that reduce the volume of wastes generated and ensure proposer waste segregation; developing strategies and systems along with strong oversight and regulation to incrementally improve waste segregation, destruction and disposal practices with the ultimate aim of meeting national and international standards; where feasible, favoring the safe and environmentally sound treatment of hazardous HCW (e.g. by autoclaving, microwaving, steam treatment integrated with internal mixing, and chemical treatment) over medical waste incineration, building a comprehensive system, addressing responsibilities, resource allocation, handling and disposal. This is a long-term process, sustained by gradual improvements; raising awareness of the risks related to HCW, and of safe practices; and selecting safe and environmental friendly management options, to protect people from hazards when collecting, handling, storing, transporting, treating or disposing of waste. Government commitment and support is needed for universal, long-term improvement, although immediate action can be taken locally. 33 program (to be implemented by DHHP with WB funding) will be consistent and effective. 93. Given complexity (technical, financial, and social) of HCWM issues and the limited knowledge and capacity of the HCF owner and key MOH technical agencies, in light of rapid COVID-19 pandemic, PCO will (a) ensure that an effective arrangement for waste collection and disposal off-site has been established preferably through contracting for the services with the provincial agencies who are responsible for management of the on-going landfill in Sekong province; (b) facilitate discussion on how to ensure that adequate resources will be made available for safe and effective operation of the HCF in SK until the end of December 2023 – as a minimum; (c) ensure safety of local communities including preparation and implementation of a Community Health and Safety (CHS) plan during operations of the HCF (see Chapter 7); and (d) facilitate the discussion between the HCF owner and the MOH technical departments (DHR, DHHP, NCLE) on scope and priority of the TA to be conducted under Component 4 to support the HCF owner and the technical department (see below). However, during construction and operation of this proposed HCF, MOH regulations and guidelines will be applied while infectious wastes will be treated using autoclaves before collection and transportation to the existing landfill. To address public 94. It is expected that new autoclaves will be procured for the proposed HCF. At this stage, it is considered that application of the on-site autoclave is appropriate. Operational experience however suggested that the autoclave should be operated by a qualified staff and that the water to be used is very clean (to meet standard) while electrical voltage can also affect operations of the machine. The Project will also provide technical support for a TA (Component 4), capacity building, and tipping fee for the off-site waste treatment and/or disposal. 95. In this context, it is expected that the scope of the TA to be implemented under Component 4 of the Project will also include (a) the development of SOP and supports to ensure safe and effective operations of the proposed HCF including those related to HCWM taking into account the recommendations provided in the ESMF of the Project; (b) ensuring availability of necessary equipment, PPES, and other consumables materials; (c) preparation of the CHS for operations, and (d) on-the-job training and monitoring of the HCWM procedures and operations of autoclave, etc. 96. In 2020-2021, WHO conducted a quick assessment on issues and priority for actions to address waste management in central, provincial, and district hospitals in Lao PDR and provided general recommendations on priority actions (see Annex 6C). At this stage, it is expected that safe HCWM for the proposed HCF will follow the WHO recommendations for HCWM in district and provincial hospitals (up to 150 beds) in Lao PDR. These recommendations have been discussed with the HCFs owners, DHR, and other technical departments in light of the GOL regulations, the TA to be provided (under Component 4), and the ESMF technical guidelines provided in Annexes III and IV. Results from discussion and agreement has been used for updating the proposed mitigation measures during operations (see Table A6.1 of Annex 6). 34 5.2.2 Healthcare Wastewater Treatment System 97. Based on the current design of the proposed HCF, prefabricated septic tanks (capacity 9,000 to 27,500) will be installed for each major building (Please refer to Table 2). It is expected that the effluent will be discharged into a pit and chlorination will be made to the effluent as needed before it is discharged into the public drains or natural water bodies. Nonetheless, before water discharging to public drain and/or natural water bodies. Nonetheless, before water discharging to public drain and/or natural water bodies, the water quality testing will be made regularly, this is to ensure that the discharged water meet WB water quality standards or Lao PDR standards. 98. The sewage and wastewater treatment system are identical for ICU, Ward and Laboratory buildings. All wastewater (sewage) generated from toilet will flow through the prefabricated septic tank for sedimentation process, leaving sludge for the anaerobic bacteria inside the tank to be degraded by the biological process. The effluent from septic tank will enter filter tank where it will be treated by the automatic chlorination system before entering the underground seepage tanks. Whereas the other wastewater from sinks, and floor drains will flow to grease trap tank first to collects and reduces the amount of fats, oils and greases (FOG's). This prevents drain blockages, foul odors and potential pest infestation. It follows the same process as the sewage but without flowing into septic tanks (Please refer to Figure 5 and more details are in Annex 2B). 99. Storm water Drainage: the storm water and water runoff shall will be drained from the catchment area via the existing drainage lines and discharge into public drainage. Table 2 Capacity of Septic Tanks No. Building Septic tank Grease Automatic Manhole Seepage Retentio and filter tank trap tank chlorine water tank n pound filling quality machine inspection (L) (L) (L) set (L) (L) 1 ICU Building "A" 6,000 2,000 PUBLIC WARDS 1,200 1 30,000 10,000 2 12,000 4,000 Building "B" LABORATORIE 3 4,000 1,600 1,200 1 21,000 7,000 S Building "C" Total Volume 22,000 7,600 2,400 2 51,000 17,000 Figure 6 - Sewage and Wastewater Treatment System 35 • Environmental cleaning and disinfection Activities 100. Under the Component 1 (Activity # 1.4), the Project will also finance COVID- 19 preventive and disinfection activities related to environmental cleaning, water quality, and infectious waste management at the community level. It comprises (i) capacity building for management and disposal of infected wastes; (ii) improvement of quality of water, wastewater treatment system, provision of clean drinking water, hygiene and sanitation; (iii) capacity building for health worker and community in water and sanitation; (iv) provision of disinfection and sanitation equipment and supplies; (v) development of guidelines, instruction and standard; (vi) printing of guidelines, instructions and standards; (vii) dissemination of guidelines, instruction and standard; (viii) procure vehicle for conducting disinfection activities and adequate cleaning of chemicals and properly fitting PPEs for male and female workers working on waste management; (ix) community disinfection; and (x) Covid-19 vaccine – waste management, including sharps waste and COVID-19 waste management on-site (separation, storage, labeling, on-site transport and treatment, etc.,). 101. The National Center for Environmental Health and Water Supply (NCEHWS) will implement the sub-component under the leadership and guidance of Department of Hygiene and Health Promotion (DHHP), and in collaboration with other development partners such as WHO, UNICEF, and Save the Children International. This component will cover the costs of training and supervision, development and production of training materials, renovation of wastewater treatment plants especially healthcare facility that provide treatment for COVID-19 patients and isolation and improving the quality of water supply at health facilities and key communities where there are a high number of people at risk, procurement of supplies and equipment for disinfection and environmental cleaning at the community level through awareness raising and praying alcohol by health officers to kill corona virus where there is outbreak. 5.3 Potential Impacts on Social Issues, Health, Safety, and Climate Change 102. Potential impacts to the health professional and workers during operations. As suggested in the ESMF, health care of workers, most of who are women play a critical role in outbreak response and are the backbone of a country's defenses to limit or contain the spread of disease. They face higher risks of potential COVID-19 infection in their efforts to protect the greater community and are exposed to hazards such as psychological distress, fatigue and stigma. This also includes other hospital staff that may be particular at risk, including ambulance drivers and hospital cleaners. These groups are one of the first on the priority list for vaccination. Activities will include detecting and monitoring of virus, assessing of sample and treating of patients. The key risk is infection with COVID-19 resulting from visiting suspected cases in a hospital, quarantine center, testing in a laboratory, improper manage of infectious waste, taking care of patients can lead to illness and death of those workers and close to them. Careful planning and implementing of specific measures for health care of workers has been suggested and integrated in the IPC (Annex IV of the ESMF) and it will be applied during the development of technical guideline and/or SOP for safe and effective 36 operations of the HCF. All workers will be trained and provided with PPEs to prevent infection from COVID-19. WHO guideline on preventing social stigma as a result of COVID-19 will also be used as Infection Prevention and Control procedure will be followed. This is to ensure that workers will implement their work properly and safely against the COVID-19 pandemic and are not overly fatigued or stressed. 103. During operations of the proposed HCFs, the mitigation measures and guidelines for operation of HCFs, laboratory, and isolation wards provided in the ESMF Annexes III and IV will be discussed with DHR and DHHP and when possible integrated into the existing guidelines and regulations as appropriate. 104. Potential impacts as a result of exclusion of vulnerable or disadvantaged groups during operations. As identified in the ESMF, these groups, including vulnerable ethnic groups, may not be able to access project benefits timely and/or effectively due to a lack of knowledge and limited information on the services in their service areas, discrimination in accessing the services, and/or stigma syndrome if they test positive for COVID-19. Vulnerable groups may also face indirect impacts, particularly women, elderly, ethnic groups and those with disabilities, if focus is redirected on COVID-19 and they are unable to receive needed support on reproductive health, vaccination for children, ongoing treatments, etc. These groups may also face challenges in accessing the immunization program, due to access, transportation costs, and lack of information. 105. In line with the SEP, the ESMP has addressed these issues and will ensure that appropriate information to be provided to these groups is relevant, understandable and culturally appropriate. As part of the finalization of the O-ESMP of the proposed HCFs, available information reflecting the needs of ethnic and vulnerable groups that are being developed as part of the communications strategy and IEC materials, will be applied during the operations of the proposed HCFs. Environmental - Drawing, ESS screening, Compliance ESMF, ESCP - Detailed design, LMP, SEP, SS- - Technical Certificate (ECC) and POM ESMP (C-ESMP, Specification and O-ESMP) - Contract document Construction permit Figure 7 Sequence of documentation requirement for HCFs construction 106. Potential impacts of improved climate resilience and safety. As noted in the ESMF that due to location of the existing land, the land elevation may have to be increased. In this case, measures to mitigate potential impacts on local flooding and access, particularly for people with disabilities, will be incorporated into the detailed design and local people will be consulted before construction can begin. Training on risk prevention and mitigation measures related to natural disaster, climate change and flooding risks of the Covid-19 treatment facilities as well as those related to local fire will also be considered. Improved knowledge and awareness of local communities on these risks could help save lives and assets and reduce the potential for adverse climate related impacts on vulnerable peoples. 37 5.4 Summary of Impacts and Proposed Mitigation Measures 107. Annex 3 presents the ES risks while Annexes 5 and 6 identify site-specific risks, impacts, and mitigation measures during design/construction and operations of the proposed HCF in PDH. Table A5.1 of Annex 5 (Part A) identifies the risks and mitigation measures considered during the planning and design while Annex 5 (Part B) identified those to be implemented by the contractor. The ES requirements identified in Part B including Table A5.2 and the 4 attachments have been incorporated into the CD as the ES obligations (ESO) and PiSECCON (the CSC) will conduct day-to-day supervision. The HCF owner and PHO/DHO in cooperation with local authorities and local communities will conduct monthly monitoring and report the ESO compliance to responsible authorities. DHR and PCO will conduct monitoring on the construction of HCFs in Sekong, Attapeu and Champasack province and during the operation of these HCFs together with relevant authorities every six months to ensure the construction and operation of HCFs are well organized and measures are applied appropriately. the monitoring reports in the ESMR will be submitted to the WB. 108. During operations of the proposed new HCF, PCO, DHR, and DHHP will discuss with the WB on the application of the proposed mitigation measures as identified in Annex 6 (Table A6.1) to ensure safe and effective operations of the proposed HCF in light of the TA to be implemented under Component 4 and discussion is on-going9. 109. Table 3 provides a summary of the proposed mitigation actions to be carried out as part of the SS-ESMP. Table 3 Summary of issues and actions to be conducted for the proposed HCFs Key Activities/Issues Proposed Mitigation Measures Remarks Planning and design. Key Discussion on the layout and design of the HCF This is made in risks include ensuring proper including procurement procedures and parallel to the design and operations of the documents are completed and WB clearance is preparation of proposed HCF including waste expected by end of October 2021. this ESMP. management in light of COVID-19 treatment Construction. Risks include • All measures are incorporated into Annex See Annex 5 Part site clearance, demolition of 5 while Annex 5 Part B including Table A and Part B. existing buildings, and A5.2 and 4 attachments have been decommission or site closure. incorporated into the contract documents Impacts are expected to air, (CD) as part of the ES obligations (ESO). noise, vibration, wastes, local • Contractor is required to comply with the traffic, safety to workers and ESO while PiSECCON will supervise and local communities, etc. report the progress and compliance. • An ECC will be issued before construction begins. 9 The discussion is taking into account the scope and implementation arrangement of the technical assistance to be implemented under Component 4 taking into account MOH regulations and the generic guidelines provided in the Project ESMF (especially Annex III and Annex IV) related to operations of the HCF and laboratory, procurement of goods, and technical assistance and training. 38 Operations. Risks include • Annex 6 and Table A6.1 identifies the risks TORs for the those related to HCWM and proposed mitigation measures being TAs are being management (segregation, discussed. It will be updated taking into discussed storage, collection, treatment account the generic guidance provided for between WB, and/or disposal (on-site and operations of the HCF and laboratory as WHO, PCO, off-site). The provincial provided in Annexes III and IV of the DHR, and landfill was not properly Project ESMF. DHHP. constructed without lining, • To ensure safe and effective operations of See reference in leachate collection and the proposed HCF and to meet the short- Table A6.2 in drainage system. The term need, MOH existing regulations and Attachment 1 of healthcare waste is not SOPs will be applied while the Project will Annex 6. properly managed and also provide supports on training and disposed (opening and appropriate facilities, equipment, materials, dumping) due to the lack of supplies, and chemicals (waste containers, standard incinerators, waste bags, autoclaves, PPEs, and autoclaving and budget to disinfection chemicals, etc.) before construct a sanitary landfill. operations begin at least to the end of 2023. The design has incorporated Discussion is on-going. appropriate layout and key • Other issues related to community health facilities (water supply, and safety (CHS), climate resilience, and electricity, HVAC, septic emergency preparation are also being tanks, and small building for discussed. laundry and waste storage). • PCO will facilitate follow-up discussion with DHR and DHHP on these aspects and next steps including on the draft TOR for the TA to be implemented under Component 4. Procurement, Training, and Technical Assistance Procurement of goods • Apply GOL regulations and SOPs on IPC See guidance in and HCWM procedures. However, these Table A6.3 of regulations and SOPs will be updated taking the Attachment 1 into account generic guidance provided in of Annex 6. Annexes III and IV of the Project ESMF. Training / workshop and • The training on IPC, HCWM and ESMF See guidance in technical assistance will be provided to HCF staff who operate Table A6.4 of the HCF. the Attachment 1 of Annex 6. CHAPTER 6. STAKEHOLDER ENGAGEMENT & INFORMATION DISCLOSURE 6.1 Stakeholder Engagement 110. Information disclosure. To ensure project stakeholders, including potential affected parties and interested parties, are engaged in consultation process and provide continuous feedback throughout the HCF cycle, key information about the new HCF in SPH will be disclosed before consultation is carried out. Information about the HCF 39 will be prepared and disclosed for the purpose of consultation during stages of HCF design, construction, and operations. Engagement of project stakeholders, including local authorities, local people, SPH, and relevant stakeholders are important to obtaining stakeholder’s meaningful feedback for incorporation into HCF design, construction and operations. 111. Before consultation is carried out, groups that are targeted for consultation sessions should be notified in advance of the consultation plan. They will be provided with key information about the new HCF to prepare themselves before participating in the planned consultation session. For the construction of the HCF in Sekong Provincial Hospital, information to be disclosed include key information such as overview of the HCF in SPH (purpose, activities, benefits, etc.), environmental and social risks and potential impacts associated with the construction and operations of the HCF, proposed mitigation measures, and the complaint handling procedure (grievance redress mechanism), etc. 112. Consultation methods. To keep stakeholders engaged throughout the HCF design, construction, and operations, consultations with stakeholders will be consulted in line with the Project’s ESMF and SEP. It is noted that traditional form of consultation, such as face-to-face meeting (preferred by ethnic groups) will be used when there are no restrictions of social gathering due to COVID-19. However, when restriction of face- to-face meetings are applied, virtual meetings will be employed instead. In areas where people do not have access to phones or facilities for allow for virtual meetings, loudspeakers will be used to reach out to the local people and feedback from them can be collected through local village leaders who will consolidate and provide the consultation results to the project. 113. During HCF preparation, particular attention will be given to vulnerable groups, including ethnic people, who live together with the mainstream population. These ethnic groups will be further engaged during HCF construction and monitoring process through the public consultation and grievance redress mechanism, and they will be also engaged by construction contractors as paid workers to generate income for their family. 114. Given COVID-19 restriction on social gatherings, consultation has been conducted irtually with HCF stakeholder on the SS-ESMP for the new HCF in SPH using Google Meet software. During HCF construction and operations, face-to-face meetings will be organized if there is no restriction on social gathering. Observation of local regulations on COVID-19 prevention measures will be strictly applied as guided by the time of consultation. Necessary measures, such as social distancing, wearing medical masks, use of sanitizers, etc. will be applied when small-size group meetings are allowed for consultation purpose. Efforts will be made to ensure relevant stakeholders are timely consulted for their meaningful feedback, particularly those who are from disadvantaged/vulnerable groups. In addition to virtual live consultation, MOH’s Facebook and website will be used as an additional channel to disclose project updates and receive feedback from project stakeholders. 40 115. Consultation during preparation of draft SS-ESMP. The Executive Summary of the draft SS-ESMP for the HCF in SPH was disclosed on 5 October 2021 on the website of PCO prior to consultation. Virtual consultation sessions were conducted with selected stakeholders in the morning of 12th of October 2021. Summary of the consultation results is provided in Annex 8 of this SS-ESMP. Stakeholders participating in the virtual consultation via Google Meet supported the implementation of the proposed HCF, including the proposed mitigation measures for risks and potential impact identified for SS-ESMP during construction stage. Key comments related to design and construction of the HCF had been incorporated into the SS-ESMP (Construction stage, Annex 5). PCO will continue to facilitate consultation among DHR, DHHP, PHO/DHO, and the HCF owner to collect the feedback of these stakeholders on the identified risks, impacts and proposed mitigation measures for the operations of the proposed new HCF during the preparation and implementation of the TA which will be unfold under Component 4 to support capacity building and provision of supplies. 116. Consultation during Implementation of SS-ESMP. In line with the SEP, more consultations will be conducted during the implementation of the SS-ESMP. All consultation sessions to be conducted during SS-ESMP preparation, implementation and HCF operations, are summarized in Table 4 below. Table 4 Consultation Plan for the SS-ESMP for the HCF in Sekong Provincial Hospital Topics for consultation Methods Target stakeholders Responsibilities During Preparation of SS-ESMP (prior to SS-ESMP Approval) ▪ Overview of the HCF in ▪ Public face-to-face meetings ▪ Relevant local authorities ▪ PCO (lead & SPH (purpose, activities, ▪ In case of COVID-19 ▪ Potential affected oversight) benefits, etc.) restriction, virtual meetings peoples (health care ▪ CSC ▪ Potential environmental will be hold using Google professionals, visitors, (implement) risks and impacts Meet, Whatsapp, Facebook, patients in SPH, and ▪ DHR ▪ Proposed mitigation Telephone (to be confirmed community members, (coordinate) measures with target stakeholders including vulnerable ▪ Grievance redress ▪ Use of loudspeakers in groups, ethnic minorities mechanism community area to disclose and health volunteers in ▪ Channels and contact project information the vicinity of the SPH. information (for ▪ Distribution of project questions, comments, information leaflet (PIB) (at complaints) least one week prior to consultation) ▪ Feedback at village level are collected through village leaders and/or local IP leaders (when social gathering is restricted) During Implementation of SS-ESMP (during Construction of the HCF) Key consultation topics: ▪ Public face-to-face meetings ▪ Relevant local ▪ Contractor ▪ Construction schedule ▪ In case of COVID-19 authorities (implement) ▪ Potential risks and restriction, virtual meetings ▪ Potential affected ▪ CSC (lead and impacts peoples (health care oversight) 41 Topics for consultation Methods Target stakeholders Responsibilities ▪ Mitigation measures, using methods mentioned professionals, visitors, ▪ GRM above patients in SPH) and ▪ Distribution of project community members in information leaflet (PIB) the vicinity of SPH, summarizing key consultation DHOs topics Work progress (including ▪ Disclosed on dedicated ▪ Contractor, ▪ Contractor and implementation of SS- channels (e.g. PCO website ▪ CSC CSC ESMP) and Facebook) ▪ PCO ▪ Public meetings (if necessary) ▪ DHR ▪ Feedback at the village level ▪ DHOs will be collected through village leaders and/or local IP leaders (when social gathering is restricted) During Operations of the HCF Regular Update on ▪ Disclosed on dedicated ▪ Local communities ▪ DHR Implementation Results of channels (e.g. websites, ▪ Local authorities ▪ PCO the HCF operation Facebook of DHR, PCO) ▪ General public 117. Key feedback from Public Consultation: - The construction of the new HCF will generate noise, air pollution and other impacts due to operations of machinery during demolish and construction. Therefore, relevant authorities and stakeholders must be highly attentive to these risks and impacts and be responsible for avoiding/minimizing these risks and impacts. - If the project still has budget, we would like to propose to have a proper hole or landfill for disposal glass tubes, waste glass, medicine tubes. This is due to the past experience showed that Sekong Provincial Hospital had problem with this issue, which has not yet been solved. Response was provided to clarify that Project budget is limited and it has to be used for addressing emergency issues and needs related to COVID-19 response. Nonetheless, provincial government is considering relocation of the existing landfill site and this will reduce the risks of contamination/ spreading of pathogen that the general public is currently concerned about. At the new location, the landfill will be designed to better reduce health risks associated with healthcare waste at landfill site. - Project owner’s management measures are considered to be complete. However, construction company (Contractors) should be aware of these risks that will arise during construction should manage these risks very effectively. - Where possible, use local labor is encouraged to control and reduce the risk of outbreaks of COVID-19 from other outsource and to create jobs for the surrounding people as well as within the province. - Once the project is completed, training on risk prevention of Covid-19 should be provided to the cleaning staff of the Sekong Provincial Hospital to have more self- protection. 42 6.2 Community Relations and Safety during Construction 118. Construction activities for this ESMP include demolition, site clearance, construction works, and site closure. As suggested in the ESMF, during construction, contractors will ensure that local authorities and the local residents nearby the construction sites will be informed in advance of works taking place, including the estimated duration. In the case of work required in response to an emergency, local residents will be advised as soon as reasonably practicable that emergency measures are taking place. Effective and timely cooperation with the local police will be required to avoid issues related to traffic congestion, road safety, and complaints from the local residents and general public. 119. The Contractor will be required to respond quickly to emergencies, complaints or other contacts made via the ‘Comment Box’ or any other recognized means and liaise timely with the emergency services, local authority officers and other agencies who are in charge of resolving the incidents or emergency situations. This emergency plan, process, contact telephone and procedure as well as GRM has been shared and discussed with local authorities and communities during the public consultation on SS- ESMP of the HCFs conducted in mid of October 2021. The Contractor will manage the construction sites, workers’ camps, and workers in accordance with the ES obligation identified in Part B of Annex 5 including the 4 attachments and the signing of the workers’ Social Code of Conduct (SCOC). Direct workers and contracted workers (Contractor and subcontractors’ employee) may be subject to relevant disciplinary actions if violation of the SCOC is found. 6.3 Community Relations and Safety during Operations 120. As suggested in the ESMF that ethnic groups and remote communities need to have access to concise and easily understandable information about how to i) avoid contracting COVID-19 and good hygiene; ii) COVID-19 symptoms; iii) what to do/what medical facilities to call or visit if experiencing COVID-19 symptoms and iv) immunization schedule including benefits, timing and priority groups. A focus for remote ethnic communities should also be on steps to take when traveling outside of their area, and potential measures for self-isolation for members that have been in areas with documented COVID-19 cases, in order to protect remote communities. User and audience-friendly IEC materials must be developed with the needs of ethnic groups in mind, to be used during the visit to these communities. These materials development is responsibility of National Center for Communication and Education for Health (CCEH) which they have the budget under this project to produce such materials. Project workers must take extreme cautionary measures while visiting remote and/or ethnic communities as they could risk bringing the virus to very remote areas. Medical attention to ethnic groups must be sensitive to their needs. More over these project workers will be fully vaccinated before participating and working for the project. 121. The HCFs owner (SKH manager in this case) is responsible for ensuring effective and safe operations of the HCFs including safety of the patient, local communities, and general public. The HCFs owner and the technical department responsible for the HCFs construction and/or operations (DHR and DHHP) will maintain effective operations of 43 the HCFs and keep the LA/LC informed periodically. A Community Health and Safety (CHS) plan for operations of the HCF will be prepared and implemented as part of the O-ESMP and the progress is included in the E&S monitoring report (ESMR) to be submitted to the WB. Consultation with key LA/LC on the concerns and safety issues will be made during the preparation of the CHS plan which will be conducted with the TA support (Component 4). PCO and PHO will help securing a contract for solid waste management (collection and disposal) services for the proposed HCF. 122. A Community Health and Safety (CHS) plan for operations of the HCF, including the Emergency Preparedness and Response Plan (EPRP), will be prepared with support from the TA to be implemented under Component 4. The implementation progress of the HCF operations will be included in the ES Monitoring Report (ESMR) that will be submitted to the WB. Consultation with key local authorities and communities on their concerns and safety issues will be conducted during the preparation of the CHS plan and EPRP. The CHS Plan will aim to avoid and mitigate CHS risks associated with the increasing number of patients and patients’ relative during the HCF operations These potential risks include transmission of communicable disease, particularly COVID-19, among people present in the HCF such as patients, HCF profession staff and workers, patients’ relatives, visitors, and community member outside the HCF premise. The CHS plan will include awareness raising activities for patients and local communities which will be conducted through dissemination of key information in the form of leaflet, posters, video clips, and social media (WhatsApp, Facebook), and virtual trainings where necessary. Warning signs, barriers or perimeter fences will be installed in and around the prohibited/restricted areas of the HCF and waste disposal facilities to keep people and animals away. CHAPTER 7. RESPONSIBILITY OF KEY ACTORS FOR HCF CONSTRUCTION AND OPERATION 7.1 Implementation and Arrangement of responsible actors • Key Responsibilities of PCO 123. PCO is responsible for completing (a) detailed designs and contract documents for the three HCFs and (b) SS-ESMPs for the three HCFs as well as to be responsible for supervising the construction. PiSECCON has been working closely with PCO, DHR, staff of other technical agencies, PHOs, and DHOs for the tasks (a) and (b) above and will provide guidance, supervision, and monitoring on contractor’s performance regarding the ES obligations that has been included in the works contracts. 124. To speed up the construction of the three HCFs, including the PDH, MOH has accelerated and completed the selection of contractor through direct contract and the construction contract will be signed with PCO on behalf of DHR. The contractor will be responsible for implementation of the proposed ES obligations and GRM (ESO- GRM) that has been incorporated into the Contract Document and contractor must follow C-ESMP as ES commitments which is equivalent to the proposed mitigation measures under responsibility of contractor as described in Annex 5 Part B including 44 Table A5.2 and the 4 attachments. The HCF owner will need to comply with O-ESMP after the construction completed. PiSECCON (as the CSC) will be responsible for day- to-day supervision of the construction quality and submit the implementation progress to PCO including ensuring contractors’ compliance with the ESO-GRM and GOL requirements and provide training, as needed. The PCO will be responsible for periodic monitoring and reporting to the WB. The GOL will issue the Environmental Compliance Certificate which is necessary before construction of the civil works can begin. • Key Responsibilities of PiSECCON 125. As the CSC, PiSECCON is responsible for, but not limited to, the followings: • Ensuring that all Works are constructed to the prescribed quality in accordance with the specifications of the bidding documents and Work Contracts and quality assurance systems; • Monitoring construction methods and quality control; • Certifying the quality of works conforms to the specifications and drawings; • Providing technical assistance to MOH during the Defects Liability Period; • Performing any and all other items of work not specifically mentioned below, but which are necessary and essential to successfully supervise and control the construction activities in accordance with the plans, specifications and terms of contract; • Verifying and approve the soft drawings together with as build drawings and submit to PCO and the HCF owner prior launching guaranty period; • Providing day-to-day supervision, guidance, and training to contractor and ensuring contractor’s compliance with the ES obligations to the Works Contract including those to be required by GOL, the HCF owner, local authorities, and local communities as well as submitting quarterly ES Compliance Monitoring Report to PCO, and • Submitting Quarterly E&S Compliance Monitoring Report to PCO. • Key Responsibilities of Contractors 126. Technical qualification of the construction contractors will include: (i) knowledge of material supplies, price variations over time in the respective locations; (ii) the capacity to prepare realistic cost estimates for works in the area; (iii) good local site knowledge to assist in the preparation of a realistic bid; (iv) sound technical knowledge on construction methods and procedures based on established industry norms; and (v) access to a current database of local and material information to enhance the quality of the contract. 127. The contractors will be responsible for: • Ensuring that all works are carried out in accordance with established industry standards and procedures of the Government, • Ensuring that construction shall be carried out in compliance with ESO-GRM that have been included as part of the works contract and with specific guidance from PiSECCON and/or as requested by PCO. 45 • PiSECCON and PCO will also ensure that notification of site access is issued only after consultation with local community is completed as per guidance in Annex 5 of this SS-ESMP, • Implementing the construction in accordance with the technical specifications outlined in the contract, • Maintaining monthly progress reporting to PCO on implementation progress identifying areas of concern that have the potential to delay the implementation progress, • Submitting claims in accordance with the contract in a timely manner with full documentation as specified in the contract, • Upon completion of the works program, decommissioning the works to ensure it functions as designed, and • Preparing a statement of construction that details the extent and nature of the structures completed under the contract to facilitate handover to the operational entity assign responsibility for subsequent operation. 128. The contractor will also be required to assign the ESO-GRM focal point to be responsible for ensuring effective coordination and timely implementation of the ESO- GRM activities before construction begins. The focal point will receive, address, record and report on grievances and provide response to feedback that may be raised by the local communities regarding construction work. The ESO-GRM focal point will also be responsible for resolving grievances that may be submitted by contractor’s workers on OHS and working conditions. • Key responsibilities of HCF owner 129. As the HCF owner, SPH will be responsible for, but not limited to, the following: • Collaborate with PiSECCON, the Construction Supervision Company for ensuring that all works are constructed to the prescribed quality in accordance with the specification of the HCF based one the approved drawings. • Provide regular monitoring on construction and ensure that all risk and impact mitigation measures are applied; • Work in close conjunction with PHO, DHO, DHR and PCT to certify the quality of works in conformity to the Works’ specifications and drawings; • Collect feedback from patients and/or visitors and report if there is any grievances that arise during the construction and operational period; • Submit HCF operations report including ESMP implementation aspects. 130. During operations, the HCF owner will be responsible for operations including waste management with assistance of DHR, DHHP, and PCO. Key responsibility of HCF owner will be, but not limited to, the following: ● Supervise daily administrative operations of HCF ● Develop and implement effective policies for all operational procedure ● Implement and compliance with Environmental, Social, Health and Safety guidelines ● Train new medical officers on Environmental, Social, Health and Safety ● Resolve potential issues for patients and visitors 46 ● Stay up-to-date with healthcare regulations ● Collect feedback from patients and/or visitors and report if there is any grievances that arise during the operational period. ● Summary of key challenges and corrective measures and report to DHR and PCO 7.2 Capacity Building 131. During construction, PiSECCON will provide guidance and training to the contractor and their staff and workers on the ESO-GRM and a training plan will be submitted to the PCO. The first training will be conducted before the start of construction. Scope of the training will include, but not limited to, community health and safety (CHS), GRM, OHS, road safety (including training of drivers), ESHS requirements, ESCOPs and good housekeeping practices during construction. PiSECCON will prepare a training plan to be endorsed by PCO as soon as the contractor is mobilized. It is expected this plan will be available by end of December 2021. Budget for the training has been included as part of the PiSECCON’s contract with PCO. 132. During operations, which is expected to begin in mid-2022. the HCF owner is responsible for operations of the proposed HCF. However, due to limited capacity and budget, PCO and MOH technical departments (e.g. DHR and DHHP) will provide training, technical assistance, and budget supports as needed. Scope of the training and technical assistance (TA) will focus on safety measures related to COVID-19 and the SOPs to be updated taking into account MOH regulations and the generic guidelines that have been provided in the Project ESMF (Annexes III and IV) (See details in Annex 6). The budget and scope of the TA are being discussed among PCO, MOH technical departments, and WB team, The training is expected to be implemented by mid of 2022 or just the HCF is completely constructed. 133. Regarding capacity building for HCF staff, main TA and training topics include, but not limited to, provision of (a) equipment, PPEs, disinfection chemicals/solutions, etc.; (b) contract on waste management services (separation, collection, on-site/off-site treatment and disposal); and (c) a series of TAs to assist in the finalization of the SS- ESMP during operations taking into account GOL regulations and various technical guidelines and good practices (waste management, floods, emergency response, preparation of specific plans and measures during operations), (d) procurement of an autoclave for disinfection of laboratory equipment (capacity of 200 liter) and another autoclave for disinfection of medical wastes (capacity of 110 liter) as needed. PCO will prepare an action plan to complete the discussion process on the implementation of the SS-ESMP for operations and a training plan to be provided to the three HCFs and submit to WB for comment by end of 2021. 47 CHAPTER 8. GRIEVANCE REDRESS MECHANISM 8.1 GRM principles. 134. In line with the SEP, a grievance redress mechanism (GRM) will be established and operational during the implementation of the SS-ESMP for the new HCF. There are three types of GRM that will be in place and functioning during construction and operations of the new HCF: GRM for a) community members and patients, b) health professionals and contractor’s workers, and c) SEA/SH victims. Patients, community members from local villages and other affected individual and groups in and around the HCF site will have access to the GRM through a) a summary of GRM provided in the Project Information Booklet, b) explanation through virtual consultation sessions, c) full GRM provided in the ESMP that was disclosed in hard copy at SPH, public meeting halls of communes around the SPH, and e) website of MOH. Potentially affected people can also make direct inquiries for support on how to use project GRM by contacting the Reception of the SPH, 135. The Project’s GRM, including those for the parent project, was built on existing country system to receive and resolve complaints in a timely and effective manner. Grievances are handled at each municipal/provincial referral hospitals and from the village up to national levels through the existing Village Mediation Unit or Committee and are resolved to the satisfaction of affected parties. At national level, the Secretariat of the National Task Force for COVID-19 Prevention and Control established serves as a focal point for GRM with its Website: https://www.covid19.gov.la and hotline call-in center (#165 and 166) . Persons or parties who believe the Project has caused an adverse impact on them can lodge their grievance through the project’s GRM channels such as hotline, social media. Stakeholders who want to provide comments and suggestions to strengthen the design and implementation of the proposed HCF and to activities implemented by PIEs under the parent project can also provide their comments through the project’s GRM channels or hotline. The project’s GRM is designed to ensure it will: • Provide affected people with avenues through which their complaints or disputes (arising in connection with HCF activities) are resolved; • Ensure grievance is resolved in a manner that is culturally appropriate and mutually acceptable –to the satisfaction of complainants; and • Avoid the need for aggrieved parties to resort to judicial proceedings. • Complainants bear no cost associated with the resolution of their grievances. 8.2 GRM for community 136. Grievances that arise within the SPH will be handed by the Hospital. Grievances that arise in the project communities –from the village up to national levels, will be handled through the existing Village Mediation Unit or Committee (VMU/C and fiduciary structures/agencies from district to national level). A dedicated hotline and WhatsApp number has been established at PCO. GRM focal points have been assigned within PCO 48 to handle, monitor and report on the grievance resolution process and results. The GRM includes the following steps: a) Step 1 – Hospital level: Complainant lodges/ discusses project-related grievance to the hospital. Grievances may be any things related to construction of the HCF, the availability of medical equipment, treatment of patients with COVID-19, performance or conducts of health workers, COVID-19 vaccination schedule, exclusion from project benefits, etc. b) Step 2 – PCO level: If the Complainant is not satisfied with the grievance resolution result in Step 1, grievance can be submitted to the PCO in writing and/or verbally through PCO’s hotline. 137. Complainant can also submit a grievance directly to PCO as Step 1 for any project related issues. In case complainant is not satisfied with the resolution from the steps above, they can initiate their case to the court of law. 138. During the HCF construction and operations, PHO/DHO and the HCF owner will also establish its GRM to ensure that complaints, if any, will be timely addressed and results will be appropriately recorded. Based on consultations during HCF preparation, construction and operation, PCO will assess whether the above GRM is adequate to deal with concerns on construction and operations, particularly concerns during construction process, such as concerns over workers’ camps, noise, vibration, and dust, etc. that are generated during construction process. Particular attention will also be given to concerns related to handling of infectious and hazardous wastes during operations, or whether a separate GRM is necessary (See Sample Form for GRM Monitoring and Recording in Annex 7). 8.3 GRM for healthcare professionals and contractors’ workers: 139. For health professionals and workers, the existing government GRM will be used and this has been adopted for the Project. In addition, the hotline, WhatsApp and Facebook could be used to lodge a grievance. 140. For construction workers, the contractor will be required to a) set up a Comment Box at the workers’ camp. The Comment Box will have the mobile number(s) of the CSC and PCO so that the worker can make an anonymous complaint directly to the PCO. In addition to the above-described formal procedures for community GRM, the contractor will be required to appoint a GRM focal point to be responsible for receiving, handling, and reporting on grievances that are lodged by local communities, patients and HCF/hospital staff during the construction period. The GRM focal point of contractor will also be responsible for grievance related to social, health, and SEA/SH/VAC related incidents, if any. The Contactors’ GRM focal point will be responsible for receiving the grievance and reporting to the CSC and the PCO via provincial and district health offices as needed. The contact details, including phone number of the contractor’s GRM focal point, will be displayed in the village office and at the construction site. 141. GRM for the community: patients, local villages and affected people in and around the subproject site during the construction and operation of HCFs: Building on the existing 49 country system to receive and resolve complaints and grievances in a timely and effective manner that satisfies all parties involved. Grievances can be submitted if someone believes the Project is having an adverse impact on the community, the environment, or on their quality of life. Stakeholders may also submit comments and suggestions to strengthen the design and implementation of the proposed HCFs. Specifically, the GRM: • Provides affected people with avenues for making a complaint or resolving any dispute that may arise during the course of the implementation of the activities; • Ensures that appropriate and mutually acceptable redress actions are identified and implemented to the satisfaction of complainants; and • Avoids the need to resort to judicial proceedings. 142. In line with the SEP, grievances will be handled at the hospital, and from the village up to national levels through the existing Village Mediation Unit or Committee (VMU/C and fiduciary structures/agencies from district to national level). A dedicated hotline and WhatsApp will be established with focal points assigned to PCO to handle, monitor and report on the status of grievances received and addressed. The GRM includes the following steps: • Step 1: Complainant discusses project-related grievance with the respective hospitals being supported by the project or VMU. For instance, a grievance may be related to the upgrading works of the facility, the availability of medical equipment, treatment of patients with COVID-19, performance or conduct of health workers, vaccine schedule, exclusion of project benefits, etc. • Step 2: If the Complainant is not satisfied with how the grievance is handled, or if the grievance is not specific to a hospital, the grievance can be raised directly with the PCO and/or hotline. 143. The above steps are at no cost to the complainant. Once all possible redress has been proposed and if the complainant is still not satisfied then they should be advised of their right to legal recourse. 8.4 GRM for SEA/SH victims: 144. Under the project, the GRM for SEA/SH mainly serves to: (i) refer complainants to local GBV service provider; and (ii) record resolution of the complaint. The following principles will be applied. These principles recognize victim as principal decision makers in their own care, and treat them with agency, dignity and respect for their needs and wishes. o Multiple channels are in place for easy access and lodge complaints; o SEA/SH victims will be referred to local GBV service provider for immediate support if they make a complaint directly to PMU; o Confidentiality of victims are protected. GM operator PCO will keep SEA/SH allegation report confidential. o No identifiable information on the victim shall be collected and stored in Project Grievance Logbook; 50 o Costs of operating the SEA/SH GRM will be financed by the project; Channels for lodging SEA/SH complaints: o Channel 1 – AP can submit a complaint, verbally or in writing, to the HCF o Channel 2 –Alternatively, AP can lodge their complaint, verbally or in writing, GRM Focal Point of PCO. 145. All SEA/SH related grievance will be addressed directly by the Lao Women Union (LWU) who has extensive experience in SH/SEA issues as per Bank’s requirements since many of their staff have been involved in many WB-funded projects. Nonetheless, they will need more specific training and guidance when they are invited to provide the services to the project. CHAPTER 9. ESMP MONITORING AND REPORTING 146. In accordance with the ESCP, PCO will monitor the implementation progress of the SS-ESMP and prepare and submit a report on E&S implementation to the WB regularly on a semi-annual and annual basis. These reports will be submitted no later than 45 days after the end of each reporting period (June and December each year). Progress of the SS-ESMP implementation will be included in these progress report. Due attention will be given to address the issues related to the ESHS which is defined in this SS-ESMP to cover, but not limited to, the implementation progress of this ESMP, stakeholder engagement activities, and GRM. The records related to the GRM will follow the GRM procedures provided in the ESMF and is included in Annex 7 of this SS-ESMP. If an accident occurs, the event and action will be informed to WB within 24 hours and the investigations and submission of report will be prepared as agreed with WB. Annex 7 also provides a sample for an accident report. 147. For this SS-ESMP, PiSECCON will be responsible for day-today supervision and monitoring of the SS-ESMP during construction. PiSECCON will submit implementation progress reports to PCO and the HCF owner and will also provide training to the contractors and their personnel and workers to ensure that the contractor’s performance is in accordance with the ESO-GRM requirements set out in the Works contract. Specific training program will be submitted to PCO (and copied to the WB). 148. During operations, the HCF owner (Sekong Provincial Hospital) will be responsible for ensuring safe and effective operations of the proposed HCF. PCO will ensure that adequate PPEs, budget, training, and technical assistance will be provided to the new HCFs to ensure its safe and effective operations. During the Project implementation, the HCF owner will submit periodically the HCF operations report to the PHO/DHO and DHR with a copy to PCO of DPC and to the with the WB, if agreed. 149. At project level, PCO will monitor the implementation progress of this SS-ESMP and report the monitoring results in PCO’s Environment and Social Management Monitoring Report (ESMR) and submit it to the WB semi-annually. 51 9.1 Contractor Monitoring 150. The Contractor will be required to attend a series of meetings with PiSECCON and/or Field Engineers to ensure that all compliance conditions and procedures are clearly understood and actions can be implemented on the ground. As part of the day-to-day supervision of works, PiSECCON/Field Engineers are also responsible for supervision and Contractors’ compliance with the ESO-GRM and include the monitoring results in their progress reports. 151. An indicative location and number of monitoring sites as well as frequency of monitoring is provided in Table 5 below while details can be adjusted, as needed during construction. Table 5 Monitoring Plan – Construction Phase (CSC is PiSECCON) Responsibility Aspect/ Parameters Frequency Location Checking/ Impact Monitoring Verification Air quality Dust deposition Weekly Near key CSC PCO rates and water sensitive spraying receptors (HCF and communities and schools nearby the site and along the construction material transportation routes). Sites should also include receptors near quarries and borrow pits. Noise and Interview with Weekly Near key CSC PCO vibration patients and no sensitive noisy activities receptors (HCF during the night and communities time and schools nearby the site and along the construction material transportation routes). Sites should also include receptors near quarries and borrow pits. Wastewater Effluents from Weekly Waste water CSC PCO worker camps discharges from 52 Responsibility Aspect/ Parameters Frequency Location Checking/ Impact Monitoring Verification (visual camps and inspection) offices If needed: Field measurements. Laboratory analyses: Total and fecal coliforms, total nitrogen, total phosphorous, COD, and BOD Drainage, Drainage failure, Weekly Drainage at the CSC PCO Erosion and maintenance worker camp and Sediment requirement for construction sites transport drainage and and borrow pits. erosion / sediment control (visual inspection) Waste Use of Weekly Workers’ camps, CSC PCO management appropriate Construction (general waste waste bins, areas, ancillary and hazardous separation and facilities, waste) proper disposal operational of waste (visual infrastructure inspection) Workers’ camp General Weekly Workers’ camps CSC PCO management housekeeping, OHS, SCOC (Visual inspection) Implementation Compliance with Weekly Construction CSC PCO of ES all sites, camps and obligations environmental, affected occupational, communities, health and safety other project sites measures as specified Annex 5 Part B Grievance Complaint log Weekly Affected villages CSC PCO monitoring book and and workers’ (GRM) comment box camps 53 9.2 Non-Compliance Reporting Procedures 152. The Contractor and its subcontractors, if any, will comply with the ESO-GRM requirements. To ensure that necessary action has been undertaken and that steps to avoid adverse impacts and/or reoccurrence have been implemented, PiSECCON and the Contractor will submit progress report to PCO periodically. Any serious incidents or accidents of non-compliance that may have serious consequence will be informed to PCO and the WB within 24 hours through the Accident Reporting Procedure and Form (Annex 7) . In the event of working practices that may be deemed dangerous either to the HCF owners, the local authorities, or other concerned agencies, Contractors must take immediate remedial action. The Contractor must keep records of any incidents and accidents as well as any corrective/remedial actions that have been taken. The records of non-compliance that could be practically addressed (not cause serious impacts) will be reported to PCO monthly, with a copy to DHR and to the WB. 9.3 Monitoring and Reporting during Operations 153. The HCF owner (Sekong Provincial Hospital), MOH technical department (DHR and/or DHHP) and the PHO/DHO are responsible for ensuring safe and effective operations of the proposed HCFs after construction has been completed. Monitoring form provided in Annex 7C could be used as a reference monitoring format for SPH. However, in light of the COVID-19 pandemic and limited capacity and budget, provide TA and allocate adequate funds for operations of the proposed HCF for at least to the end of the Project closing date. CHAPTER 10. IMPLEMENTATION COSTS AND BUDGET 10.1 Costs. 154. Cost for this SS-ESMP implementation include costs for (a) implementation of ESO- GRM including measures to mitigate potential risk related to UXO (which is included as part of the construction cost); (b) supervision of ESO-GRM and ensure compliance which will be carried out by PiSECCON, including training (which has been included in the contract with PiSECCON); (c) implementation of the proposed mitigation measures during operations at least to the end of December 2023; and (d) procurement of equipment, supplies, and provision of training for HCF staff such as supervision, monitoring, and reporting to PCO and technical departments. 155. Costs for (c) and (d) are being discussed taking into account the TA to be implemented under Component 4, including cost for waste management services for the proposed HCF, excluding the costs for the 2 ESF consultants and their travels and training activities to be conducted by PCO and technical departments responsible for supervision and monitoring of the SS-ESMP implementation during construction and operations of the proposed HCF. 156. To mitigate the risk and potential impacts during operations, PCO will procure an autoclave (capacity of 110 liter) to be installed at the site as well as provide other necessary equipment (bins, bag, etc.) to ensure effective and safe operations of the HCF 54 for at least 1.5 years after construction is completed which is from mid of 2020 till end of 2023 and ensure that the HCF owner has entered into a contract with proper waste collector to collect, disinfect, and manage (storage and disposal) waste safety and effectively (about $50,000 for SKH). Training will also be provided to key personnel and workers as needed. Cost for autoclave and supplies, training has been provided as part of Component 3. Cost for civil works and TA to ensure effective management of these HCFs in medium and long term has been provided as part of Components 3. Total budget for the ESMP is estimated about US$ 309,300 excluding cost for consultants under Component 3. 10.2 Budget: 157. The budget for implementation of the SS-ESMP during construction phase is included in the construction costs (total of about US$1 million) while that the ESO-GRM supervision and monitoring is included in PiSECCON contract. 158. It should be noted that budget for implementation of the mitigation measures identified in this ESMP is considered an important part of the Project cost while details can be adjusted according to the urgent needs on the ground and agreements among agencies and WB team. Table below presents an indicative cost that have been allocated for implementation of the ESMPs to ensure safe and effective operations of the proposed HCFs to be constructed and operated in Attapau (ATP), Sekong (SK), and Champasack (CPS). Cost for supervision and monitoring of ESMF implementation is include in Component 3 line “A.1”. 159. A budget of about US$ 150,000 has been allocated to Component 4 to ensure safe and effective operations of the proposed HCF and this will be confirmed with PCO. It is expected that the SS-ESMP for operations of the proposed HCF will be updated by end of June 2022 and the final budget can be discussed and agree between PCO and WB team. Project component and main activities Budget (USD) COMPONENT 3: Project Management and Monitoring and 309,300 Evaluation 3.1 Project management 70,000 A.1 Safeguard activities 70,000 3.2 Monitoring and evaluation 239,300 A.1 Monitoring and supervision activities 169,300 A.2 Trainings, seminars and workshops 70,000 COMPONENT 4: Strengthening Preparedness for Health 1,050,000 Emergency Respond 4 Enhancing health systems and facilities for future 450,000 . emergencies 1 TA on medical waste management, including 4.1.2.1 sharp wastes and waste water and quality of 450,000 isolation center 55 A.3 Training on HCWM (including all types of waste) 150,000 50,000 A.3.1 ATP 50,000 A.3.2 CPS 50,000 A.3.3 SK Operation support including Procurement of 300,000 A.4 equipment for the HCWM 100,000 A.4.1 ATP 100,000 A.4.2 CPS 100,000 A.4.3 SK 759,300 Total 56 Lao People’s Democratic Republic Peace Independence Democracy Unity Prosperity Ministry of Health Department of Health Care and Rehabilitation (DHR) Lao PDR COVID-19 Response Project and Additional Financing (P173817 &P175771) Annexes Site–Specific Environmental and Social Management Plan (SS–ESMP) for Sekong Provincial Hospital, Sekong Province 23 February 2022 57 Table of Contents Annex 1. Project Description and National Regulations to be Applied .............................. 59 Annex 2: Design Concept, Drawings, and Photo of the Proposed HCF ............................ 70 Annex 3: ES Screening Results and MOH Regulations to be Applied ............................... 76 Annex 3A DHR Subproject Activity and ESS Application ............................................................. 76 Annex 3B. ESS Screening for HCF in Sekong Provincial Hospital of Sekong Province ................... 77 Annex 4: E&S Information related to the Proposed HCF ................................................. 86 Annex 5: Risks, Impacts, and Proposed Mitigations Measures during Construction Phase ........................................................................................................................................... 93 Annex 6. Risks, Impacts, and Proposed Mitigation Measures during Operational Phase 135 Annex 7: Indicative forms for GRM and accident reporting ............................................ 202 Annex 8: Summary of the SS-ESMP Consultation .......................................................... 209 Annex 9: Lao PDR National Environmental Standards (Revised 2017) .......................... 219 58 Annex 1. Project Description and National Regulations to be Applied 1. This Annex comprises 2 parts. Part 1 presents the Project components (Section A), implementation arrangement (Section B), and cost (Section C) as described in the Project Operation Manual (POM) approved by WB. Part 2 presents the national policies and legislations to be specifically applied to the subproject. The Project supports the activities to be implemented under Component 1. Emergency COVID-19 Response [US$25.42 million]; Component 2. Strengthening System for Emergency Response [US$3.48 million]; Component 3. Project Management and Monitoring and Evaluation [US$2.10 million]; and Component 4. Strengthening Preparedness for Health Emergency [US$2.0 million grant]. Objectives and scope of the activities are described in the Project Paper 10 Part 1 Section A. Project Components Component 1: Emergency COVID-19 Response. 2. This component supports preparedness and emergency response activities to address immediate gaps for the COVID-19 response in Lao PDR, focusing on the following areas: (i) response coordination; (ii) infection prevention and control; (iii) case detection, confirmation, and contact tracing; (iv) case management and isolation; (v) quarantine; (vi) risk communication; (vii) essential health service delivery; and (viii) allowance for health workers support staff and volunteers; (x) COVID-19 vaccine procurement; and (xi) COVID-19 vaccine deployment. Activities of this component are identified under eleven subcomponents and the activities will be implemented by key technical departments and centers of MOH (see Section B below). These subcomponents are: 1.1 Coordination – EOC Coordination at Central and Provincial. 1.2 Infection prevention and control. 1.3 Case detection, confirmation, and contact tracing. 1.4 Environmental cleaning and disinfection Activities 1.5 Case management 1.6 Quarantine 1.7 Risk communication 1.8 Essential Health services delivery 1.9 Allowance for health workers, support staff and volunteers 1.10 Covid-19 Vaccine Procurement 1.11 Covid-19 Vaccine Deployment Component 2: Strengthening System for Emergency Response 3. This component strengthens the capacity of the health system to respond to public health emergencies through investment in systems including surveillance, human resources for health, and infrastructure for health emergency response. This component supports and strengthens the capacity of health personnel (clinical, nurse and laboratory staff) and supportive staff for therapeutic, diagnostic and patient care. Key activities include (i) developing 10 https://cdc.gov.la/index.php/2021/05/20/controlprojectcovid1919052021/ 59 guidelines, providing training of health personnel on treatment guidelines, hospital infection control interventions of this emergency response for COVID-19 in Lao PDR, (ii) improve laboratory capacity, and (iii) strengthening information system for surveillance, (iv) logistic management, warehouse management, distribution, (v) improve/innovate treatment center. The activities will be implemented through the following topics and they will be implemented by key technical departments and centers of MOH (see Section B below): 2.1 Capacity building and training of health personnel on treatment guidelines, and hospital infection control interventions 2.2 Laboratory capacity 2.3 Strengthening Information Systems for surveillance 2.4 Logistic management, warehouse management, distribution 2.5 Treatment Centers and Isolation. Component 3: Project Management and Monitoring and Evaluation 4. This component finances activities related to Project management and monitoring, including the Project management unit, and Project monitoring and evaluation. In collaboration with other development partners and academic institutions, the Project also supports adaptive learning, evidence generation, and knowledge sharing from the Project implementation to support effective implementation of emergency response and collection of good practices within the country. Key activities include: (i) recruitment of PCO contractual staff and technical consultants; (ii) support for procurement, financial management, environmental and social framework (ESF) implementation, monitoring and evaluation, and reporting; (iii) operating expenses; and (iv) evidence generation and learning activities. 5. Monitoring and evaluation will be implemented in coordination with technical departments responsible for implementing activities using the agreed planning, monitoring, and evaluation tools including the compliance with ESF requirements. Collection, use and processing (including transfers to third parties) of any personal data collected under this Project will be done in accordance with best practices, ensuring legitimate, appropriate and proportionate treatment of such data. The activities will be implemented through the following topics and they will be implemented by the Project Coordination Office (PCO) of DPC in close cooperation with the key technical departments and centers of MOH (see Section B below): 3.1 Project Management 3.2 Monitoring and evaluation. Component 4: Strengthening Preparedness for Health Emergency Respond 5. This component is financed by trust fund from the HEPR-TF. It aims to increase resilience of the health system to prepare for public health emergencies in priority geographical locations in Lao PDR by strengthening the health system and lifeline infrastructure. The total amount of trust fund received is 2 million US dollars and the implementation period shall cover from the project effectiveness date to 31 December 2023. The activities will be implemented through the following topics and they will be implemented by the Project Coordination Office (PCO) of DPC in close cooperation with the key technical departments and centers of MOH (see Section B below): 4.1 Enhancing health system and facilities for future emergencies 4.2 Preparing for health emergencies by developing and implementing preparedness assessments and plans, conducting simulation exercises 4.3 Estimating resource needs in case of a health emergency 60 Part 1 Section B. Project Implementation Arrangement 6. The Project Implementing Entities (PIE) as identified in the ESCP are the Public Health Emergency Operation Center (PHEOC) for COVID-19 Prevention, Control, Response and Case-management, and the MOH’s technical departments and its centers which have been assigned to directly implement the Project activities for each component, sub-component, and/or activity. Responsible MOH departments include but not limited to: (i) Department of Planning and Cooperation (DPC); (ii) Department of Finance (DOF); (iii) Department of Communicable Disease and Control (DCDC); (iv) Department of Health Care and Rehabilitation (DHR); (v) Department of Food and Drugs (FDD); (vi) Department of Hygiene and Health Promotion (DHHP); and (vii) Department of Health Personnel (DHP). Other centers under the MOH will also take part in implementing the project such as the National Center for Laboratory and Epidemiology (NCLE), the National Center for Communication and Education for Health (CCEH), and the provincial and district health offices (PHO and DHO). 7. For COVID-19 vaccines procurement and deployment, the FDD and the Mother and Child Health Center (MCHC) of the DHHP, in close cooperation of provincial and district offices, will play a leading role. A Project Coordination Office (PCO) of DPC has been assigned to mainly responsible for project management, coordination, and M&E, and provide supports to the PIE in line with the national preparedness and response plan for COVID-19. DPC in collaboration with DOF will lead the management of the Project, and the Director General (DG) of DPC is appointed as Project director. Figure 1 below illustrates the institutional arrangements of the Project. Figure 8 Implementation and Institutional arrangement under the National COVID- 19 Taskforce 8. Main roles and responsibilities of the PIE are as follows: • Implement project related activities including control and prevention of infection of the COVID-19, particularly activities under Component 1 and 2. 61 • Prepare annual work plan and budget and submit to the PCO for consolidation and concurrence. • Provide monthly and quarterly progress reports to the PCO, following the MOH routine reporting timeframe. • Collaborate, monitor and evaluate implemented activities and budget outlined in the annual work plan of the project departments and its centers. • Coordinate and ensure linkages between project activities of related stakeholders in and, or outside of the health sector. • Prepare technical report of respective project activities, including results, statistics, photos of the activities under implementation. • Coordinate and cooperate with PCO on (a) the ESF screening for submission to WB for clearance before undertaking the activities; (b) the preparation of ESF instruments and tools (such as the ESMP, ESCOP, LMP, etc.) as agreed with WB after the screening; (c) after WB clearance of the ESF documents, instruments/tools, implement the activities taking into account the measures to mitigate the ES risk and negative impacts; and (d) report the implementation progress, issues, and actions to PCO and/or WB as agreed. • Report on the progress of implemented activities and use of advance money to the PCO. 9. Oversight committees. Given involvement of many technical agencies involved at national and subnational levels with active supports from international development partners (IDP), four oversight committees have been established to ensure effective coordination and decision making at national and subnational levels as well as among key sectors. There are some specific task forces under these committee as well. Key committees are highlighted as follows while details are provided in the project paper: i. The National Committees and Task Forces. This committee is responsible for providing policy and strategic advice to all government agencies in response to COVID-19. It is chaired by a deputy Prime Minister and comprising representatives from relevant government agencies, including MOH. ii. Public Health Emergency Operation Center (EOC). Within MOH, the Technical Committee (or EOC) for Prevention, Control, Response and Case- management of COVID-19 Outbreak, led by the Minister of Health and comprising representatives from concerned technical departments, was activated in January 2020 and has a mandate of providing strategic advice and overseeing the implementation of measures in combating COVID-19. The EOC directly reports to the National Task Force. iii. COVID-19 Vaccine Management Committee. MOH has established the COVID-19 Vaccine Management Committee to oversee the COVID-19 vaccine procurement and deployment and to coordinate the IDP and government agencies. This committee is established under the umbrella of the EOC. PCO will work closely with the committee on the vaccine related activities under the AF and continue reporting to the EOC. The committee is leaded by the vice minister and co-supervised by Cabinet and FDD. iv. National Committee for Adverse Event Following Immunization (AEFI). AEFI National Committee has been established to monitor, investigate, report 62 and case management of the AEFI. The MCHC will work with AEFI to ensure the adverse event is reported through the DHIS2. The PCO will work closely with MCHC, FDD, AEFI committee in addressing the AEFI issues 10. Project Coordination Office (PCO). MOH established a PCO, led by the Project director who is also the DG of DPC with two deputies: (i) DG of DOF and (ii) Deputy Director General of DPC. PCO will function as executive agency for the Project, who will directly report to the EOC, and is responsible for day-to-day management of the project, including administration, financial management, procurement, preparation of environmental and social instruments, consolidation of workplan and budget from implementing agencies, ensuring compliance with legal covenants, environmental and social sustainability framework of the Bank, and monitoring and evaluation. More detailed functions, roles and responsibilities and staff assigned are outlined in the Ministerial Decree No. 0848/MOH dated 09 April 2020. Main roles and responsibilities of the PCO are as follows: (i) Planning and Coordination, (ii) Financial Management; (iii) Procurement and contract management; (iv) Implementation of ESF Requirements; and (v) Monitoring and Evaluation. Details are provided in POM. Part 1 Section C. Project activities and estimated budget. 11. Overall project activities, budget allocation and departments/units responsible for the implementation. 63 64 PART 2. Policies, Laws, and Regulations to be Applied 1. This part comprises 3 sections. Section A presents the GOL policy, laws, and regulation to be applied to the activity which are in line with those identified in the ESMF. Section B present existing capacity of MOH while Section C presents the WB's ESF policy being applied to the Project and it will be applied in the ESMP. Part 2 Section A. National policies, laws and regulations 2. The Project ESMF identified key national laws and regulations to be applied to the Project which will also applied to the proposed HCF and they can be highlighted as follows: 65 Environment protection law (2012), the environment and social assessment (2013, 2019), hazardous waste management (2015) and pollution control (2017) issued by the Ministry of Natural Resources and Environment (MONRE) and the guidelines on Consultation with Ethnic Groups issued by Lao Front for National Development (2012) which provides guidance and process of conducting consultation with all ethnic groups affected by both public and development projects largely in line with the ESS10: Stakeholder Engagement and Information Disclosure. 3. Laws, Regulation and Institutional setting in the Public Health Sector. For health sector, as part of the Public Sector Health Care Strategy aiming to increase capacity on modern health care services, GOL updated the 2005 Law on Health Care (LOHC) in 2014 (No. 58/NA, dated 24 December 2014). The 2014 LOHC describes the principles, regulations and different measures relating to the organization, activities, management and control of health care activities, in order to ensuring that all citizens, societies and communities have access to equal, full, equitable and quality health care services while protecting the rights and interests of health care professional. According to the law, the healthcare administrative agencies consist of (1) the MOH at the National level; (2) the PHO at the provincial level, and (3) DHO at the district level. There is also a health center (small hospital) established at the cluster (Khum Ban) level and dispensary in some villages. A special Taskforce was also set up at national, provincial, district and village levels for the emergency case such as COVID-19 pandemic. The National Assembly is approving for implementation of the related laws while the MOH is leading and coordinating the line ministries at all levels including other sectors and relevant local administrative authorities to implement all health-and COVID-19 related activities. 4. Some regulations issued by MOH for implementation of health care specific issues include (a) Sharp Waste Management Guidelines, issued by the Director General of the Department of Planning and Coordination (DPC/MOH), dated10 October 2019, (b) Law on Preventive Vaccination (immunization) approved by the National Assemble on 09 August 2018, (c) Law on Prevention and Control of Communicable Disease, approved by the National Assembly on 19 December 2017, (d) Law on Health Care, approved by the National Assembly on 22 January 2015, (e) Decision on Healthcare Waste Management (No. 1373, dated 23 November, 2017), and (f) Decision on hygiene condition of healthcare facilities (No. 1667, dated 15 August 2018), printed by DHHP in 2018. MONRE has also established a Decree on hazardous waste management (2015) and is updating this decision. 5. On vaccination programs, the following national legislations, laws and policies have been developed by FDD for regulation of medicines, vaccines and other health products, including for accepting donations and ancillary products. The key ones are: Law on drugs and medical products, 2011; Regulation on Business Establishment for Medicine and Medical Product Company, 2017; Pharmaceutical Import-Export Company Regulation, 2017; Regulation on Drug and Medical Products Donation, 2003; Regulation on destroying of drug and medical products, 2016; Order of Ministry of Health on monitoring and law enforcement for unregistered medicine, 2011; Drug registration, 2003; Regulation on pharmaceutical manufacturer, 2004; Regulation on GMP, 1999; and Current Banned Drug List, 2015. On 2nd January 2009, the FDD published a legal notice (No. 1189/FDD) to “ensure the quality, efficacy and safety of imported drugs and medicinal products for use in heath related projects” in Lao PDR. Please refer to the Project ESMF (Section 3) for more details. 6. Laws, regulations, and institutions setting in labor sector. National Assembly approved on December 2013 a Labor Law which superseded a labor law adopted on December 27, 2006. The new labor law defines the principles, regulations and measures on administration, monitoring, labor skills development, recruitment, and labor protection in order to enhance the quality and productivity of work in society, so as to ensure the transformation to modernization and industrialization aimed at safeguarding the rights of employees and employers, as well as the legitimate interests and the continual improvement of their livelihoods, while contributing to the promotion of investment, national socio-economic development, and regional and 66 international links. This labor law applies to all employers, registered and unregistered employees, Lao employees working for foreign organizations, and foreign employees working within the Lao PDR. 7. Section VIII of the 2013 labor law provides a mandatory obligation for all parties on Labor Occupational Health and Safety (OHS) to protect labor health and safety, and labor accident and occupational diseases. It sets out an obligation of all levels to take care of labor occupational health and safety include the obligation of employer, obligation of employee, obligation of the designing and supplying entity, and obligation of responsibility parties. The Ministry of Labor and Social Welfare (MLSW) at the national level, the Department of Labor and Social Welfare at the provincial level, the Division of Labor and Social Welfare at the district level and the unit of Labor and Social Welfare at the village level have the responsibility to implement the provision of this labor law. 8. In November 2016, MLSW issues a regulation identifying type of work with hazardous condition not be hired for workers younger than 18-years old. 9. In addition, existing national legislations including Law on Civil Servants (2016) and Decree on Code of Conduct for Civil Servants (2019), Law on Preventing and Combating Violence Against Women and Children (2006) and Panel Law (2017) contain provisions which are largely consistent with ESS2 and ESS4. These legislations provide regulations and measures to manage, prevent and address potential misconduct among civil servants including health workers and outsourced volunteers, community health and safety issues and risks associated with Sexual Exploitation and Abuse (SEA), Gender-based Violence (GBV) and Violence Against Children (VAC) that may occur under project. The Lao government has also ratified a number of ILO conventions, including on forced labor, child labor, minimum age and equal remuneration. 10. GOL Policy and Procedure to combat COVID-19. In March 2020 and April-May 2021, considering the outbreak of COVID-19 pandemic in neighboring countries such as China, Thailand, Vietnam, and others, the GOL took strict actions to prevent infection within Lao PDR. Three policy and guideline were issued on 13 March 2020 to control COVID-19 transmission and infection i.e. (a) guideline on prevention of the transmission and infection of COVID-19 at international airport, land border, and transportation stations; (b) guideline on prevention of the transmission and infection of COVID-19 at suspected to be infected area or temporary quarantine center; and (c) guideline on prevention of the transmission and infection of COVID-19 at public place (hotel, guesthouse, offices, schools, and others). During the outbreaks, the Prime Minister issued an order on restriction of people travelling and allows GOL officers to work from home periodically to prevent the outbreaks. Vaccination has also been provided through COVAX as well as procurement of Covid-19 vaccines when possible. Part 2 Section B. MOH Capacity and ESF Implementation Performance 1. GOL/MOH Capacity and E&S Implementation Experience. The WB and other development partners (ADB, US Center for Disease Control (US CDC) through WHO, UNICEF, Save the Children, Korea, China etc.) have been providing technical and financial support to build GOL capacity to address pandemic and health issues during the past 15 years and recently for the response to COVID-19. The MOH is responsible for coordination and implementation of these projects and has experience implementing several WB financed projects including the application of WB safeguard policies including the on-going Health Governance and Nutrition Development Project (HGNDP, P151425), Health and Nutrition Service Access Project (HANSA, P166165), and the Lao PDR COVID-19 Response Project (LCRP, P173817). The HGNDP and HANSA apply the WB Safeguard Policies while the LCRP applies the ESF. The staff previously assigned by MOH for the implementation of these projects will also be responsible for the Project and ensuring that project activities are in compliance with the WB’s ESF requirements. 67 2. ESF implementation experience. All the Project Implementing Entity (PIE) of MOH including PCO of DPC have limited capacity and does not have any experience on the implementation of ESF, thus extensive discussion and implementation support has been provided by WB ESF team. The first ESF consultant (ESFC1) is onboard in September 2020 while the second the (ESCF2) is board in mid-February 2021. Given that the activities will apply different level of ESF instruments and only those that are related to civil works will require the preparation of an ESMP including ICWMP, IPC, HCWMP, LMP, SEP and/or ESCOP, mobilization of national consulting firm and/or a qualified national consultant may be necessary to ensure that the facilities are properly designed and documents are prepared for WB clearance before construction begins. As assigned by the national PIE, the provincial and district offices and/or the hospital or HCF owner can play the roles of supervision of civil works and implementation of activities at local level in close coordination and cooperation with other agencies and key stakeholders at local level. 3. It is also noted that during 2014-2019, MOH has established a number of regulations related to hygiene and waste management including those related to hazardous and sharp wastes (see Annex 3). 4. For practical reasons, it has been agreed that each PIE will be treated as a subproject and an E&S screening will be conducted to assess the risks and impacts while preparation of an ESS workplan for each subproject (each PIE) will be sent to WB for clearance. The two ESCFs at PCO will also provide training on the ESF implementation especially those related to ESMF, ESMP, SEP and LMP application as well as be responsible for supervision, monitoring, and preparation of ESF implementation report to WB. The ESFCs will also review adequacy and compliance of all activities and include the results in the first ESF implementation monitoring report (ESMR). The WB ESF team will provide guidance on the training and supports during the preparation of the ESF instruments as needed. Part 2 Section C. WB’s ESS Relevancy and Guidance Related to COVID -19 1. WB’s ESSs Relevant to the Project. The E&S risk is classified as ‘Substantial’ for the Project. The six ESSs that have been screened as relevant to the Project are ESS1, ESS2, ESS3, ESS4, ESS7, and ESS10. The Project requires the submission of an Environmental Commitment Plan (ESCP), a Stakeholder Engagement Plan (SEP), and an Environment and Social Management Framework (ESMF) to be applied and/or updated during Project implementation. The ESMF has also taken into account the national requirements as well as the application of an international protocols for infectious disease control and medical waste management. 2. The ESCP requires regular submission of a 6-month and annual ESF monitoring reports to WB while consultations and public information disclosure is required to be made throughout the entire Project cycle. It is expected that the SEP will be revised periodically and incorporate the evolving WHO guidance on Risk Communication and Community Engagement and on preventing and addressing social stigma associated with COVID-19. GRM operations will be integrated into the revised SEP taking into account the results from further communication to affected and interested stakeholders. The ESCP, SEP, and ESMF were disclosed through the website of the Food and Drugs Department (FDD) of MOH: www.fdd.gov.la. 3. The WBG’s Environmental, Health, and Safety (EHS) Guidelines, such as those related to Community Health and Safety will apply to the extent relevant. The Project will also rely on standards set out by WHO and the WB Group (WBG) in relation to COVID-19 and vaccination strategy and deployment. Beyond this immediate concern, Project implementation needs to also be responsive to the needs of marginalized and vulnerable social groups who may be unable to access facilities and services designed to combat the disease. To mitigate this risk MOH, in the ESCP, is committed to the provision of services and supplies based on the urgency of the need, in line with the latest data related to the prevalence of the cases. 68 4. WBG Response to COVID-19. During 2020, in response to COVID-19 outbreak, WBG has developed a number of guidelines in response to COVID-19 including, but not limited to, a guideline for the preparation of a Contingency Plan for Project Sites, a Technical Note on Public Consultations and Stakeholder Engagement to be applied to projects under implementation and those under preparation, a template for ESMP preparation and a template plate for ICWMP. For ESS1, the WBG also identifies risks and mitigations measures for the transactions involving specific project finance activities (i.e. works, goods, services, technical assistance, and research activities) including procurement and development of systems for deployment of safe and effective vaccines for COVID-19. In late 2020, the WB also updated the templates for the preparation of ESF documents (ESCP, ESRS, ESMF, SEP, and LMP) for COVID-19 project including procurement and deployment of safe and effective COVID-19 vaccines. The guidance has been considered during the preparation of this ESMF and the preparation of technical guidelines provided in annexes. 69 Annex 2: Design Concept, Drawings, and Photo of the Proposed HCF Following drawings are the summary of master plan, building layout, and elevations of the proposed facilities. Master Plan 70 Elevation ICU building Layout 71 ICU building Elevation Public ward building layout 72 Public ward building elevation 73 Laboratory building layout Laboratory building elevation 74 Waste management building layout Waste management building elevation 75 Annex 3: ES Screening Results and MOH Regulations to be Applied Annex 3A DHR Subproject Activity and ESS Application 1. This annex provides information on DHR subproject activities and ESS application based on the formal submission of the ESS screening for DHR subproject on 27 May 2021. The activities and/or budget may be adjusted as needed as agreed with WB. The proposed HCF is part of the Activity 2.5.2. The ESS screening for the proposed HCF is (per Table A2.1 of Annex II of the ESMF) is provided in Annex 3B below. 76 Annex 3B. ESS Screening for HCF in Sekong Provincial Hospital of Sekong Province Subproject Health Care Facility (Intensive Care Unit, Isolation Wards and Laboratory) Name Subproject The construction of three new main buildings include Intensive Care Unit (ICU), Location and Isolation Ward, and Laboratory will be located in Sekong provincial hospital, Scope of Sekong province. Small building for medical waste storage area will also be Activities constructed. Subproject DHR Proponent Estimated Proposed budget: $1.19 million Investment Start/Completion 2021-2023 Date 77 Questions Answer ESS Due diligence / Remarks and/or Next Steps relevance Actions Yes No (1) Does the Yes ESS1 If yes, prepare • Briefly explain scope of the subproject involve ESMP, ICWMP, buildings. Risks and impacts of the civil works IPC, HCWMP per HCFs during construction and including new Annexes III and operations will be determined as part construction, IV of the ESMF expansion, and apply SEP. of site specific ESMP to be prepared upgrading or New construction by the design consultant. The ESMP rehabilitation of with land will also be consistent with the healthcare acquisition is not issues and measures identified in facilities and/or eligible (see Table A3.1 to A3.8 of Annex III as waste management Section A2.3 of well as the ICWMP, IPC, and facilities? the ESMF Annex II) HCWMP of Annex IV, LPM in Annex V, and ESCOP in Annex VI. • Need to also follow the SEP and ensure comply with monitoring and specific requirements described in the ESCP. (2) Does the No ESS5 If yes, not eligible • All the buildings will be constructed subproject involve (see Section A2.3 within the existing premise belong to land acquisition of ESMF Annex MOH. Land acquisition and and/or restrictions II) resettlement will not be required. on land use? (3) Does the No ESS5 If yes, not eligible • See (2) above. subproject involve (see Section A2.3 involuntary of ESMF Annex acquisition of II) assets for quarantine, isolation or medical treatment purposes? (4) Is the Yes ESS3 If yes, prepare • Operations of the new and existing subproject ESMP, ICWMP, treatment facilities will involve associated with IPC, HCWMP per infection, toxic, sharp and any external waste Annexes III and hazardous wastes will be safely management IV of this ESMF facilities such as a and apply SEP collected, stored, and/or disposed of sanitary landfill, according to the procedures to be incinerator, or developed by DHR in line with wastewater MOH regulations and/or TG to be treatment plant for developed in line with the ICWMP, healthcare waste IPC, and HCWMP described in disposal? Annex IV of the ESMF. • The general wastes will be collected by the city/towns responsible for solid waste management and disposal. • Specific discussion on the methods and procedures to mitigate the potential risks and impacts of these wastes will be discussed and agreed with WB during the preparation of 78 Questions Answer ESS Due diligence / Remarks and/or Next Steps relevance Actions Yes No the ESMP and detailed design of the HCF. • Staff will be trained on the agreed procedures during operations and necessary disinfection equipment (Autoclave), PPEs, and other consumable materials will be procured and the budget is allocated under Activities 1.5.3 (5) Is there a sound No ESS1 If no, ensure • TA, training, and capacity building regulatory adequate training has been included in the Project framework and and capacity design and budget is allocated to the institutional building for activities 1.2.2. capacity in place effective for healthcare implementation of facility infection the ESMP, control and ICWMP, IPC, healthcare waste HCWMP, and management? apply SEP (6) Does the No ESS1, If no, provide • Appropriate measures will be subproject have an ESS3 capacity building, included in the ESMP while adequate system in budget, and additional TA will be provided place (capacity, prepare/implement under the AF (HEPR-TF) to reduce processes and ESMP, LMP, and management) to SEP this risk address waste? (7) Does the Yes ESS2 If yes, prepare • Apply the updated LMP (Annex IV subproject involve LMP and apply of ESMF) to be conducted by recruitment of SEP PCO/DPC in close consultation with workers including the DHR. direct, contracted, primary supply, • Apply the SEP throughout the HCF and/or community construction and operations workers? (8) Does the No ESS2 If No, provide • Appropriate measures will be subproject have capacity building, included in the ESMP while appropriate OHS budget, and additional TA will be provided procedures in prepare/implement under the AF (HEPR-TF) to reduce place, and an ESMP, LMP, and adequate supply of SEP this risk PPE (where necessary)? (9) Does the No ESS2 If No, establish a • A GRM will be established at DPC subproject have a GRM, provide as well as at the HCF during GRM in place, to capacity building, construction and operations of the which all workers budget, and HCFs. DPC/PCO will report the have access, prepare/implement designed to ESMP, LMP, and GRM record in the ES monitoring respond quickly SEP report (ESMR) and effectively? (10) Does the Yes ESS3 If yes, prepare • Transportation of infectious and subproject involve ESMP, ICWMP, hazardous waste that could not be transboundary IPC, HCWMP per 79 Questions Answer ESS Due diligence / Remarks and/or Next Steps relevance Actions Yes No transportation Annexes III and disposed of onsite will be transported (including IV and apply SEP to appropriate sites as agreed with Potentially WB for example they will be infected specimens disposed at standardized sanitation may be transported from healthcare landfill or be burned at the high facilities to testing temperature incinerator. while the laboratories, and general solid wastes will be transboundary) of transported to the sites assigned by specimen, samples, the city/towns. infectious and • Details will be available during the hazardous materials? preparation of the ESMP for this subproject. (11) Does the No ESS2 If yes, apply SEP, • This will be ensured throughout the subproject involve prepare LMP per subproject implementation. use of security or Annex V of this • However, if this is later found to be military personnel ESMF, and consult during WB necessary, Consultation with WB construction and/or will be made before the activities operation of are implemented healthcare facilities and related activities? (12) Is the No ESS6 If Yes, not eligible • This will be ensured throughout the subproject located (see Section A2.3 subproject implementation. within or in the of this ESMF vicinity of any Annex II) ecologically sensitive areas? (13) Are there any Yes ESS7 If yes, apply SEP • There are Lao Tai, Khmu and indigenous groups and measures Hmong groups are identified to be (ethnic groups who addressing issue present around the HCF. Initial are not of Lao Tai on vulnerable ethno-linguistic groups per Annex consultation was carried out during family meeting III of this ESMF in early 2021 to a) inform them about specified ESS7 including provide the project and its associated risks criteria) present in specific measures and impacts on the local the subproject area to address environment and local communities. and are they likely vulnerable ethnic Their feedback and suggestion on to be affected by groups in the risk management measures have the proposed ESMP, ICWMP, subproject IPC, HCWMP, been incorporated into the ESMF. negatively or and/or ESCOP During construction and operations positively? of the HCFs, these ethnic communities will also be informed that they will also be able to access the GRM to be established in their villages with information and contact detail provided, and employment opportunities for them from the subproject. • Prior to the commencement of works, CHS and OHS training will 80 Questions Answer ESS Due diligence / Remarks and/or Next Steps relevance Actions Yes No be provided by the contractor for the local communities. Necessary PPE kits will also be provided for personnel health and safety at work sites. • During the preparation of the ESMP, consultation with local authorities and communities was made in line with GOL regulations to control COVID-19 pandemic. (14) Is the No ESS8 If yes, the activity • This will be ensured throughout the subproject located will be ineligible subproject implementation. within or in the for project vicinity of any financing. (see known cultural Section 2.3 of heritage sites? Annex II of this ESMF). (15) Does the Yes ESS1 If yes, apply SEP • All BD/CD will incorporate SCOC subproject area and prepare LMP (Annex VI of ESMF) and will be present per Annex V of closely monitored by the SPN considerable this ESMF. Small consultant for Activity 1.4.2. Gender-Based civil works will Violence (GBV) apply ESCOP per • PCO/DPC and ESFC will ensure and Sexual Annex VI of this compliance with the measures Exploitation and ESMF. All identified to address these issues as Abuse (SEA) risk? workers must be described in the ESMF. trained and signed the social Code of Conduct (16) Does the Yes ESS1 If yes, prepare • Actions similar to the item (13 subproject carry ESMP and apply above) will be applied risk that SEP disadvantaged and vulnerable groups may have inequitable access to project benefits? (17) Is there any No OP7.60 If yes, consult • No follow-up actions territorial dispute Projects WB. Governments between two or in concerned agree more countries in Disputed the subproject and Areas its ancillary aspects and related activities? (18) Will the No OP7.50 If yes, consult • No follow-up actions subproject and Projects WB. Notification related activities on (or exceptions) involve the use or Internatio potential pollution nal of, or be located in Waterway s 81 Questions Answer ESS Due diligence / Remarks and/or Next Steps relevance Actions Yes No international waterways11? Conclusions 1. Proposed ESS risk rating and justification is as follows: • Risk rating is considered “Substantial”. However, land acquisition and resettlement will not be required as these HCFs to be constructed are located in the land owned by the MOH/PHO and free of encumbrance. The works will include demolition of existing buildings and construction of new buildings and operations of the HCFs will require safe and effective management of general wastes and other medical wastes (infectious, sharps, toxic and hazardous, etc.). Key risk and impacts during construction are mainly associated with works activities including construction waste, dust, noise, CHS, and OHS as well as traffic safety during the transport of construction materials and equipment. Due to the COVID-19 outbreak regulation and small scale of works, local contractors and suppliers will likely to be hired to do the works and thus labor influx from overseas or neighboring countries will not be used for this project. However, some skilled labors unavailable in the sub-project area may have to be mobilized from other districts and provinces. These labor migrants could potential bring about CHS issues including communicable and infectious diseases, particularly COVID-19 and SEA, GBV and VAC and other social issues (public order). • A consulting firm, PiSECCON is on board and is preparing the site specific ESMP as well as to complete the preparation of DD and BD/CD and supervision of the improvement works. With the AF, it is expected that another consulting firm will also be mobilized with funding support from HEPR-TF to verify the results from the DD and BD/CD including adequacy of the ESMP and the risks and mitigation measures, especially those related to waste management. It is expected that if possible additional machines and/or equipment and medical suppliers necessary to ensure effective management of occupational health and safety (OHS) as well as effective management of infectious and other medical and/or toxic wastes from the HCF to be financed by the project taking into account the risk and priority needs for addressing emergency preparedness and response of the HCF. 2. Proposed ESS Instruments: i. To prepare an ESMP for the HCF covering all activities related to construction and operations of the HCF including ensuring that the mitigation measures to mitigate impacts during operations are included in the DD while those to be conducted by contractors is included in the BD/CD. The ESMP will identify locations (with map), nature and scope of the activities to be conducted during construction and operations of the HCF, and identification of site-specific issues and mitigation measures to be carried out to mitigate risks and negative impacts. The ESMP will also include, but not limited to, site-specific ICWMP, IPC, and/or HCWMP, LMP, and ESCOP including COC to be applied by the contractors and their workers in 11 International waterways include any river, canal, lake or similar body of water that forms a boundary between, or any river or surface water that flows through two or more states. 82 line with the requirements described in Annexes III, IV, V, and VI of the ESMF. The ESMP will also identify the responsible entity and ensure that adequate budget will be allocated to ensure effective implementation of these plans/instruments including procurement of necessary equipment and machines, medical supplies, etc. ii. To incorporate the final ESCOP including COC (Annex VI of the ESMF) into BD/CD of all construction works and WB clearance before bidding will be ensured. iii. To apply IPC (Annex IV of ESMF) and measures identified in Annex III Table A3.3 of ESMF to all activities related to procurement of goods and medical supplies, as appropriate. iv. To apply measures identified in Annex III Table A3.4 of the ESMF to all TA and training, and capacity building, as appropriate. v. PCO of DPC will also ensure compliance with the LMP and SEP to be applied to the project during construction and operations stages. vi. PCO of DPC assisted by ESFCs will provide guidance to the consultant and conduct periodic supervision and M&E as well as submit the ESMR to WB. Close consultation with WB ESF specialists will be necessary. Remarks. (1) DHR is committed to work closely with PCO of DPC and other agencies/entities to assist the provincial health department ensuring effective and timely implementation of the ESF instruments as proposed above and as agreed with WB. 3. Eligibility: I confirm that the HCF activities/subproject is eligible for Project financing (i.e. not fall in the list identified in Table A2.2 of Annex II of ESMF shown in Attachment 1 of this document). Sign by Provincial Health Department: …………………….…………………………… Position: …………………………………………………………Date ……………..………………….. Sign by PCO of DPC: ……………………………………………… Position: …………………………………………………………Date:………………………………… 83 ANNEX 3C. MOH specific regulations to be applied Box 1. 2017 MOH decision on healthcare waste management of HCFs (decision #1373, dated 23 Nov 2017 Art.1. Objective and Scope Art.2. Definition Art.3. Healthcare waste Art.4. Waste container Art.5. Use color coding system for waste containers Art.6. Waste container labeling Art.7. Waste segregation Art.8. How to collect and store waste at health facilities Art.9. Waste transport within health facilities Art.10. Use the label when attaching it to the container Art.11. Removal of hazardous waste from health facilities Art.12. Waste storage procedure Art. 13. Waste storage duration Art.14. General waste disposal Art.15. Infective waste, physical and sharp waste disposal Art. 16. Drug disposal Art.17. Destruction of chemical wastes Art. 18. Destruction of genetically harmful wastes Art.19. Disposal of radioactive waste Art.20. Disposal of pressure container Art.21. Disposal of waste containing metal Art.22. Survey of the origin and composition of waste at health facilities Art.23. Budgeting and health education development Art.24. Reducing the amount of waste Art.25. Monitoring the safety and health standards of employees working on waste Art.26. Risk assessment Art.27. Safety uniform Art.28. Personal cleaning Art.29. Organizing of the Commission Art.30. Role of the Committee on Hygiene and Environment at Health Facilities Art.31. Scope, rights and duties of the Environmental Sanitation Management Committee Art. 32- 39 Monitoring and Evaluation Box 2. MOH decision on environmental health and hygiene standards, (decision #1667, dated 15 Aug 2018 Art 1.Objective Art 2. Definition Art 3. Scope of use Art 4. Hygiene management agency at health facilities Art 5. Role, rights, task and responsibility of organization Art 6. Appointment of a hygiene management committee at a health facility Art 7. Hygiene standard at health facility Art 8. Surrounding facility measures Art 9. Internal facility measures Art 10. Water use and water supply system standard Art 11. Water quantity standard Art 12. Water quality standard Art 13. Sediment and toilet disposal standard 84 Art 14. Waste water disposal standard Art 15. Waste management and disposal at health facility Art 16. Laundry standard Art 17. Food hygiene standard Art 18. Fire prevention standard Art 19. Standards for controlling animals and insects that carry the disease Art 20. Information and hygiene promotion standards Art 21. Gas and pressure equipment standard Art 22-28 Monitoring and Evaluation Art 29. Prohibition Art 30. Praise and punishment Box 3. Guideline on sharp waste management I. Sharp waste overview II. Healthcare worker safety III. Sharps waste management planning IV. Segregation of sharps waste V. Containment, handling and storage of sharps waste VI. Transport of sharps waste VII. Treatment of sharps waste VIII. Disposal of sharps waste 85 Annex 4: E&S Information related to the Proposed HCF This annex comprises 3 sections. Section A provides brief information Land Use around the proposed HCF in Mai Huameaung Village, Lamam district, Sekong province. Section B provides picture and photos related to existing HCF and those related to solid waste management. Section C provides basic information on site elevation, rainfalls, flood risks, and UXO related risks. Section A: Land Use surrounding the Proposed HCF Based on the data obtained from the provincial department of public work and transport, the project site is located in the UB (purple) code, which stands for the urban land. Project Location 86 Section B. Photos of Existing Conditions of SPH, Sekong Province Existing Condition of SPK Existing Sekong Landfill Provincial Land fill, 18.019 sqm, 9.5 km from town 87 Section C. Map showing elevation of the proposed site and surrounding area, rainfall, flood risks, and UXO related risks. ELEVATION PROFILE OF LAMAM DISTRICT Project Site 88 CLIMATE INFORMATION 89 90 MAP OF FLOOD RISKS 91 MAP OF UXO RISKS Project Site 92 Annex 5: Risks, Impacts, and Proposed Mitigations Measures during Construction Phase 1. This Annex comprises 2 parts. Part A describes key generic environmental and social (ES) risks/impacts and mitigation measures (Table A5.1) to be applied during construction period of the proposed HCF while Part B describes site-specific measures to be carried out by contractor which has been included in contract document. Table A5.1 was prepared in line with the generic guidance provided in the Project ESMF Annex III Table A3.1 ( construction stage) and it will be considered by PiSECCON during supervision of the construction works. Since the contractor (local contractor) has been selected during the preparation of this ESMP, the requirement described under Part B and the 4 attachments have been included in the final draft contract document (CD). 2. PiSECCON is responsible for day-to-day supervision and monitoring of contractor performance and report the implementation progress periodically to PCO. PCO will include the implementation progress during construction in the ESF monitoring report (ESMR) as required in the Project ESCP. Both PiSECCON and contractor will assign the focal points responsible for ensuring close coordination and cooperation among key parties as well as with PCO throughout the construction period. Before construction begins, PiSECCON will provide guidance and training to the Contractor to ensure compliance with the mitigation measures identified in the works contract. 3. PiSECCON will also ensure that the contractor provides the contact details including the phone numbers of a) the Contractor’s ES specialist responsible for supervision and compliance during construction and serving as the focal point to handle and report on possible work related incidents and grievances (particularly those related to community health and safety SEA, GBV and VAC) that may be raised by the local villagers, staff and patients and visitors to the hospital, and b) PiSECCON’s focal point or staff appointed to supervise all the Contractor’s workers performance, behaviors and compliance with the social code of conduct and to handle with any contract related grievance and incidents (particularly those related to occupational health and safety, SEA, GBV and VAC). Part A. Generic Environmental and Social Risks and Mitigation Measures 4. Table A5-1 identified 6 generic risks as follows: (1) The design of the isolation and treatment centers or of the new HCF does not meet technical requirements, increasing risk of spreading COVID-19 in health facilities; (2) Dust, noise and vibration generated from construction, rehabilitation or minor civil works; (3) Solid waste generated from construction, rehabilitation or minor civil works; (4) Asbestos containing materials (ACM) generated from renovation or minor civil works; (5) Safety risks during works, health staff, patients and their relatives; and (6) Employment of workers including close working and poor living conditions in worker’s camps may create conditions for the easy transmission of COVID -19 and the infection of large numbers of people. These risks have been considered during the preparation of site-specific measures identified in Part B (see Part B below). 93 Table A5.1: Generic Environmental and Social Risks and Mitigation Measures (italic identified in the ESMF Annex III Table A3.1) Risks and Impacts Mitigation Measures Responsibilities (1) The design of the ➢ For patients with possible or confirmed COVID-19, isolation rooms should be provided and used PCO, DHR, isolation and treatment at medical facilities. Isolation rooms should: (a) be single rooms with attached bathrooms (or PHO/DPO, HCF centers or of the new with a dedicated commode); (c) ideally be under negative pressure (neutral pressure may be used, owner, and HCFs does not meet but positive pressure rooms should be avoided); (d) be sited away from busy areas (areas used by PiSECCON, technical requirements, many people) or close to vulnerable or high-risk patients, to minimize chances of infection spread; increasing risk of (e) have dedicated equipment (for example blood pressure machine, peak flow meter and spreading COVID-19 in stethoscope), but should avoid excess equipment or soft furnishings; (f) have signs on doors to health facilities. control entry to the room, with the door kept closed; and (g) have an ante-room for staff to put on and take off PPE and to wash/decontaminate before and after providing treatment. ➢ An operation manual should be prepared prior to the opening of isolation rooms to describe the working procedures to be taken by healthcare workers to protect themselves and prevent infection escape while providing treatment. The operational procedures should be of a standard to meet National guidelines for IPC in healthcare facilities and guidance from WHO and/or CDC on infection control: (a) WHO interim guidance on Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected; (b) WHO technical brief water, sanitation, hygiene and waste management for COVID-19; (c) WHO guidance on infection prevention and control at health care facilities (with a focus on settings with limited resources); (d) WHO interim practical manual for improving infection prevention and control at the health facility; (e) CDC Guidelines for isolation precautions: preventing transmissions of infectious agents in healthcare settings; and CDC guidelines for environmental infection control in healthcare facilities. Contractors must take extreme precautions when construction/rehabilitating works nearby patients, ensuring workers do not come into contact with patients. (2) Dust, noise and • The contractor(s) is responsible for compliance with relevant national legislation with respect to Contractor(s) and vibration generated from ambient air quality, noise and vibration PiSECCON construction, • The contractor(s) undertaking works shall ensure that the generation of dust is minimized and rehabilitation or minor implement a dust control plan to maintain a safe working environment and minimize disturbances civil works. for patients, staff and surrounding community 94 • The contractor(s) undertaking works shall implement dust suppression measures (e.g. water paths, covering of material stockpiles, etc.) as required. Materials used shall be covered and secured properly during transportation to prevent scattering of soil, sand, materials, or generating dust. Exposed soil and material stockpiles shall be protected against wind erosion • The contractor(s) shall ensure onsite latrine be properly operated and maintained to collect and dispose wastewater from those who do the works. • The contractor(s) should not carry out construction activities generating high level of noise during healthcare activities, especially when services are being delivered to patients. • The construction activities must be conducted during the day time only, this is to the avoid disrupting the patient or nearby hospital users. (3) Solid waste generated • The contractor(s) shall develop and follow a brief site-specific solid waste control procedure Contractor(s) and from construction, (storage, provision of bins, site clean-up, bin clean-out schedule, etc.) before commencement of any PiSECCON rehabilitation or minor financed rehabilitation works; civil works. • The contractor(s) shall use litter bins, containers and waste collection facilities at all places during works. • The contractor(s) may store solid waste temporarily on site in a designated place prior to off-site transportation and disposal through a licensed waste collector. Transport management plan in line with WBG good practice should be developed. • The contractor(s) shall dispose of waste at designated place identified and approved by local authority. Open burning or burial of solid waste at the hospital premises shall not be allowed. It is prohibited for the contractor(s) to dispose of any debris or construction material/paint in environmentally sensitive areas (including watercourse). • Recyclable materials such as wooden plates for trench works, steel, scaffolding material, site holding, packaging material, etc. shall be segregated and collected on-site from other waste sources for reuse or recycle (sale). (4) Asbestos containing • The asbestos audit will be undertaken as required prior to/at the beginning of refurbishment. Contractor(s) and materials (ACM) • Safe removal of any asbestos-containing materials or other toxic substances shall be performed PiSECCON generated from and disposed of by specially trained workers in line with the WBG guidelines on asbestos renovation or minor civil management. works. • If ACM at a given hospital is to be removed or repaired, the MOH will stipulate required removal and repair procedures in the contractor's contract. 95 • Contractors will remove or repair ACM strictly in accordance with their contract. Removal personnel will have proper training prior to removal or repair of ACM. • All asbestos waste and products containing asbestos is to be buried at an appropriate landfill and not to be tampered or broken down to ensure no fibers are airborne. Disposal of waste containing asbestos should be agreed with MOH. • No ACM will be used for renovation works. (5) Safety risks during • The contractor(s) shall comply with all national and good practice regulations regarding workers’ Contractor(s) and works, health staff, safety. PiSECCON patients, their relatives, • The contractor(s) shall prepare and implement a simple action plan to cope with risk and and surrounding emergency (e.g., fire, earthquake, floods, COVID-19 outbreak). communities. • The contractor(s) shall have or receive minimum required training on occupational and community health and safety regulations and use of personal protective equipment as well as worker’s Codes of Conduct. • The contractor(s) shall provide safety measures as appropriate during works such as installation of fences, fire extinguishers, first aid kits, restricted access zones, warning signs, overhead protection against falling debris, lighting system to protect hospital staff and patients against construction risks. • The contractor (s) shall adopt community health and safety measures to manage and mitigate risks associated with infectious and communicable (waste, air and water borne) diseases and adverse impacts on health staff, patients, their relatives and surrounding local communities. (6) Employment of • Develop contingency plans with arrangements for accommodation, care and treatment for: Contractor(s) and workers. Close working - Workers self-isolating PiSECCON and poor living conditions - Workers displaying symptoms in worker’s camps may create conditions for the - Getting adequate supplies of water, food and supplies easy transmission of • Contingency plans also should consider arrangements for the storage and disposal arrangements COVID-19 and the for medical waste, which may increase in volume and which can remain infectious for several days infection of large numbers (depending upon the material). of people. Transportation, • Ensure medical facilities are stocked with adequate supplies of medical PPE, as a minimum: storage and handling of - Gowns, aprons the vaccine, as well as vaccination campaign, - Medical masks and some respirators (N95 or FFP2) 96 could pose risk of - Gloves (medical, and heavy duty for cleaners) transmission if not - Eye protection (goggles or face screens) carefully handled. Risk from workers to • Medical staff at the facilities should be trained and be kept up to date on WHO advice and communities on recommendations on the specifics of COVID19 GBV/SEA/SH as well as • The medical staff/management should run awareness campaigns and posters on site advising COVID-19 transmission. workers: - how to avoid disease spread (cough/sneeze in crook of elbow; keep 1m or more away, sneeze/cough in tissue and immediately through tissue away, avoid spitting, observe good hygiene) - the need to regularly wash hands with soap and water – many times per day - to self-isolate if they think they may have come in contact with the virus - to self-isolate if they start to display any symptoms, but alert and seek medical advice • Wash stations should be provided regularly throughout site, with a supply of clean water, liquid soap and paper towels (for hand drying), with a waste bin (for used paper towels) that is regularly emptied. • Wash stations should be provided wherever there is a toilet, canteen/food and drinking water, or sleeping accommodation, at waste stations, at stores and at communal facilities. Where wash stations cannot be provided (for example at remote locations), alcohol-based hand rub should be provided. • Enhanced cleaning arrangements should be put in place, to include regular and deep cleaning using disinfectant of catering facilities/canteens/food/drink facilities, latrines/toilets/showers, communal areas, including door handles, floors and all surfaces that are touched regularly (ensure cleaning staff have adequate PPE when cleaning consultation rooms and facilities used to treat infected patients) • Worker accommodation that meets or exceeds IFC/EBRD worker accommodation requirements (e.g. in terms of floor type, proximity/no of workers, no ‘hot bedding’, drinking water, washing, bathroom facilities etc.) will be in good state for keeping clean and hygienic, and for cleaning to minimize spread of infection. • To minimize pressure on PPE resources: WHO advice on the effectiveness and use of PPE by general public should be followed to ensure that the supplies are not exhausted through ineffective use – this is equally important on construction sites. 97 • Other measures (such as working water sprinkling systems at crushers and stock piles, covered wagons, water suppression or surfacing of haul roads etc.) should be used for dust suppression on site before relying upon the use of dust masks (which could unnecessarily reduce the availability of N95/FFP2 masks for use by medical staff performing some duties). • Contractors and MOH should ensure that contracted workers and MOH and other relevant project staff, have medical insurance and/or are able to receive free treatment of Covid-19. • Worker accommodation and sanitation facilities to be separate for male/female as needed. • Training on community interaction and GBV/SEA to be provided for all teams, staff (civil servants and outsources staff/contractors) to ensure the teams respect local communities and their culture and will not involve in misconduct. Signing of Code of Conduct. • Any medical or other hospital staff (including cleaners) experiencing symptoms of COVID-19 or a respiratory illness (fever + cold or cough) must remain at home/isolated and report symptoms immediately to supervisors. Contractors to ensure these workers can still access pay. • Workers to access vaccinations as part of national program on a voluntary basis following the National Immunization Law (Article 15) • Training on community interaction, Codes of Conduct and GBV/SEA to be provided for all workers, including construction, drivers, cleaners, MOH staff and vaccination teams to ensure understanding of safe practices regarding COVID-19 as well as appropriate conduct with communities and signing of Codes of Conduct. • Compliance with the project’s LMP covering community workers if hired by the contractor(s). • In LMP special attention will be paid to child labor (<18 year old workers) and forced labors which are not allowed under the project. 98 Part B. Specific Environmental and Social Risk and Mitigation Measures 1. This part sets out site-specific environmental and social management plan (SS-ESMP) to be conducted by the contractor for proposed HCF in Lamam District, Sekong Province. Main objective of the SS-ESMP for Construction is to ensure that the potential environment and social (ES) risks and negative impacts during construction phase of the proposed HCF are adequately avoided, prevented, and/or mitigated. Specific objective of Appendix 5 (this Appendix) is to describe specific measures to be carried out by Contractor before and during construction including those related to the spread of COVID-19 contagion within and outside the construction sites taking into account the Government of Lao PDR (GOL)’s regulations related to COVID-19 as well as the WB’s guidelines in responding to COVID-19 pandemic related to construction works. The construction supervision consultant (PiSECCON) will be responsible for close supervision and monitoring of the proposed mitigation measures and incorporate the progress into the construction progress report to be submitted to the World Bank (WB). 2. The term “construction” use in this appendix covers the whole construction process starting from site clearance, construction, and site closure, including consultation with the hospital manager, the provincial/district health offices (PHO/DHO), and the concerned local authorities and local communities. Construction activities include site clearance and demolition of existing buildings and other structures, construction activities of new buildings and all related facilities and architecture, earth excavation and installation of related facilities and equipment, operations of borrow pits and quarries (if needed), final disposal of the construction waste and spoils, and transportation of construction materials. The Contractor and PiSECCON are required to establish and maintain effective feedback and/or Grievance Redress Mechanism (GRM) throughout the construction phase, including coordination and cooperation on the mitigation measures to prevent and control COVID-19 contagion within and outside the construction site. 3. Table A5.2 identifies specific measures to be implemented by the Contractor to mitigate the key risks and impacts related to: (i) Prevention and control of COVID-19 contagion during construction including those related to procurement of goods and supplies and training to be conducted by Contractor; (ii) Labor management and social code of conduct (SCOC); (iii) Communication and stakeholder engagement; (iv) Site clearance and safety; (v) Demolition of existing buildings; (vi) Waste and worker camp management; (vii) Construction management and pollution control; (viii) Occupation health and safety (OHS) and community health and safety (CHS); and (ix) Transportation and road safety. Objective and scope of these mitigation measures are provided as follows: (i) Infection prevention and control of COVID-19 (IPC). This subplan aims to prevent and control possible spread of COVID-19 infection within and outside the construction sites. The Contractor is also required to prepare a contingency plan to response to COVID-19 pandemic during construction works as required by the WB (see Attachment 2). The Contractor will assign the focal point to be responsible for coordination and cooperation with PiSECCON, PHO/DHO, and other concerned local authorities. (ii) Labor management and social code of conduct. This plan aims to ensure compliance with Government regulations related to the labor law as well as those related to sexual harassment (SH), sexual transmission infection (STI), gender- 99 based violence (GBV), and violence against children (VAC). All contractor staff and workers are required to sign a commitment letter regarding to the social code of conduct (SCOC) as required by WB (see Attachment 3). (iii) Communication and stakeholder engagement plan (CSEP). This plan aims to ensure effective and timely coordination between Contractor and the HCF manager, local authorities, and local communities before and during construction to mitigate potential risks related to COVID-19 contagion, safety of the HCF patient and visitors during construction, and minimize potential complaints from local authorities and communities. The plan will also include a “hotline” and feedback mechanism (GRM) to be operated by PiSECCON and/or Contractor. (iv) Site clearance and safety plan (SCSP). This plan aims to address risks related site clearance and earth excavation including those related to UXO and safety of the HCF’s patients and visitors during construction. The Contractor is required to complete installation of security wall/fence and warning signs (visible for day and night) for all construction sites before construction and demolition activities begin. Although the UXO risk is low, the Contractor is required to conduct a technical survey and UXO clearance will be conducted as needed. (v) Demolition of existing buildings plan (DEBP). This plan aims to ensure that clarity is provided on how and when the demolition will be conducted and the waste will be disposed of. Actions to address issues related to asbestos containing materials (ACM) which may be used in the past for construction of the old buildings will also be considered. Use of ACM for construction of new building will not be allowed. (vi) Waste and worker camp management (WWCM). This plan aims to address occupational health and safety (OHS) of workers at all work sites and in the worker camp as well as those measures to address safety of local communities located near the construction site. (vii) Construction management and pollution control (CMPC). This plan aims to describe the minimum requirements for the Contractor to ensure effective control of dust, noise, vibration, and other pollution that can be generated during construction phase both from the work sites and worker camp (see Attachment 4). This plan will also include an Emergency Preparedness and Response plan (EPRP) in case accidents and/or injury of Contractor’s staff and workers occur. The EPRP will also include the preparation of the contingency plan in response to COVID-19 contagion as required by WB (see Attachments 1 and 2 above). (viii) Occupational health and safety (OHS) and community health and safety (CHS). This plan aims to describe specific measures to address safety of Contract or’s workers and staffs as well as those community health and safety. (ix) Transportation and road safety management (TRSM). This plan aims to describe measures to reduce the risks related to transportation of construction materials and disposal of spoil and construction wastes including control on driving speed, training of truck driver, covering of truck, traffic management (if needed), etc. Use of an overload truck and drunk driving will not be allowed. 4. As required by the World Bank, the following measures will also be part of the contract: • Attachment 1 provides specific guidance on the basic knowledge to infection prevent and control of COVID-19 contagion to be applied within and outside the 100 work sites including those related to procurement of goods and supplies and training to be conducted by Contractor and its subcontractors (if any). • Attachment 2 provides guidance on the preparation on contingency plan to response to COVID-19. • Attachment 3 describes principles and actions related to the social code of conduct (SCOC) and specific forms to be signed by the Contractor’s staff and workers. • Attachment 4 provides technical guidance on (a) environment code of practices (ECOP) including those related to environmental health and safety (EHS) guideline and “chance finds procedures” for works contract. 5. Any serious accident related to workers, local communities, and/or other key stakeholders, especially the hospital staff, patients, and/or visitors that occur due to the construction activities will be reported to World Bank within 24 hours. Fatal accident will require extensive investigation on the root cause and agreement on the mitigation measures and follow-up actions. PiSECCON and/or PCO will provide guidance on the process. 101 Table A5.2: Proposed Measures to Mitigate Risks during Construction of the Proposed HCF (Lamam District, Sekong Province) Potential ES Risks and Mitigation Measures Responsibility Timeline/ Impacts Budget The design of the isolation and • Discussion to be conducted between PiSECCON, MOH and WB teams to ensure that • PiSECCON • Before the treatment centers or of the new design of the isolation and treatment centers or of the proposed HCFs meet technical construction HCFs does not meet technical requirements under COVID-19 health facilities. requirements, increasing risk of spreading COVID-19 in health facilities. (1) Infection prevention and control for COVID-19 (IPC) 1.1 Risk due to procurement of • Throughout the construction period, the Contractor will provide its workers with basic • Implemented • Throughout goods and supplies that may be measures to prevent COVID-19 including knowledge on wearing face-masks, hand by Contractor construction infected with COVID-19 washing, good hygiene management, social distancing, and other measures related to phase. transmitted within and outside infection prevention and control (IPC) procedures for COVID-19 contagion and the work site and camp healthcare waste management (HCWM) procedures as required by the Government • Supervised by • Cost for regulations taking into account, as appropriate, the guidelines provided by the WB for PiSECCON Contractor is this project in Attachment 1. part of the • The Contractor will ensure that adequate handwashing facilities with soap (liquid), water construction and paper towels for hand drying (warm air driers may be an alternative), plus closed contract. waste bin for paper towels are available. Alcohol-based hand rub should be provided where handwashing facilities cannot be accessed easily and regularly. • Cost for PiSECCON is • The Contractor will also promote awareness campaigns and regularly poste post key included in reminder signs around the construction site to encourage workers regularly wash hands PiSECCON’s when handling goods, and that they do not touch their face. The awareness campaigns contract and signs should be designed in different languages and in a manner that is culturally appropriate, and accessible to ethnic minorities groups, vulnerable groups and elderly (as needed). • If concerned (for example when dealing with goods that have come from countries with high numbers of infected people) a surface or equipment may be decontaminated using disinfectant. After disinfecting, workers should wash hands with soap and water or use alcohol -based hand rub. A label containing information on how materials/medical facilities/equipment should be safely handled should be available on site. 102 1.2 Risk during training of • The training will be arranged and conducted according to the GOL requirements, Same as (1.1) Same as (1.1) Contractor’s staff and workers especially those related to location of the meeting, number of participants, social above above that can cause spread of distancing, and provision of basic requirements regarding to face masks, hand cleaning, COVID-19 infection etc. • All workers and staff shall wear cloth face coverings, at a minimum, at all times when around coworker, during the training, workplace and the general public. • Frequently wash your hands with soap and water for at least 20 seconds. When soap and running water are not immediately available, use an alcohol-based hand sanitizer with at least 60% ethanol or 70% isopropanol as active ingredients and rub hands together until they are dry. Always wash hands that are visibly soiled. • Avoid touching eyes, nose, or mouth with unwashed hands. • Practice good respiratory etiquette, including covering coughs and sneezes or coughing/sneezing into elbow/upper sleeve. • Avoid close contact (within 2m for a total of 15 minutes or more over a 24-hour period) with people who are visibly sick and practice physical distancing with coworkers and the public. • Recognize personal risk factors, certain people, including older adults and those with underlying conditions such as heart or lung disease, chronic kidney disease requiring dialysis, liver disease, diabetes, immune deficiencies, or obesity, are at higher risk for developing more serious complications from COVID-19. • Wastes generated from the training will be appropriately disposed at sanitary landfill 1.3 Risk in infection of COVID- • During construction, the Contractor will conduct a risk assessment with PHO/DHO and Same as (1.1) Same as (1.1) 19 within the work site or concerned local authorities and prepare a contingency plan in response to COVID-19 in above above worker camps line with WB guideline provided in Attachment 2. PiSECCON will provide guidance and approve the plan. • The Contractor will implement the plan as part of an Emergency Preparedness Plan (see EPP below) which will be implement when staff and/or workers are found to be injured and/or ill during construction including when they are infected by COVID-19. 1.4 Ineffective coordination and • The Contractor will assign the focal point to be responsible for coordination and Same as (1.1) Same as (1.1) cooperation within and outside cooperation with PiSECCON, PHO/DHO, and other concerned local authorities. above above the construction site may increase the risks of COVID-19 contagion in the area (2) Labor management and social code of conduct (SCOC) 103 2.1 Security personnel can carry • The need to engage security personnel is not anticipated during the construction. Same as (1.1) Same as (1.1) weapon that can create risk to • However, if needed is considered necessary, PiSECCON will inform PCO prior to above above local communities and general engaging the security personnel. The PCO would be required to conduct security risk public assessment and provide recommendations on measures to manage risks associated with the security personnel. After that the Contractor will prepare a plan to engage security services which will be approved and supervised by PiSECCON. 2.2 Risks on Sexual Exploitation • SEA/SH/VAC are strictly prohibited under the Project. All staff and workers of the Same as (1.1) Same as (1.1) and Abuse (SEA), Sexual Contractor and subcontractors (if any) are required to comply with the Social Code of above above Harassment (SH), and Violence Conduct (SCOC) which has provisions on SEA/SH/VAC prohibition and prevention Against Children (VAC) (see Attachment 3). • Before construction, the Contractor will submit the signed copy of the staff and workers according to the forms provided in the SCOC. • PiSECCON will ensure that staff and worker of the Contractor and subcontractors are provided with training and sign the SCOC. • During construction, the Contractor will strictly implement and monitor the SCOC while PiSECCON will also report the implementation progress and performance of Contractor. 2.3 Risks due to non-compliance • Before construction, the Contractor is required to prepare a plan to address labor Same as (1.1) Same as (1.1) with Government laws and management as required by the labor law taking into account PCO guidance on the above above regulations related to labor application of Labor Management Procedures (LMP) as required by WB. • During construction, the Contractor will strictly implement the plan after approval by PiSECCON. 2.4 Risks due to workers coming • During preparation of the contingency plan for COVID-19 as required by WB (see Same as (1.1) Same as (1.1) from infected areas and/or co- subplan (1) above), the Contractor will consider, but not limited to, the following above above workers becoming infected measures: including workers introducing - Consider ways to minimize/control movement in and out of construction areas/site. infection into community/ - If workers are accommodated on site require them to minimize contact with people general public. outside the construction area/site or prohibit them from leaving the area/site for the duration of their contract. They shall stay in the camp that located within construction area only. - Implement procedures to confirm workers are fit for work before they start work, paying special to workers with underlying health issues or who may be otherwise at risk. - Check and record temperatures of workers and other people entering the construction area/site or require self-reporting prior to or on entering 104 - Provide daily briefings to workers prior to commencing work, focusing on COVID- 19 specific considerations including cough etiquette, hand hygiene and distancing measures. - Require workers to self-monitor for possible symptoms (fever, cough) and to report to their supervisor if they have symptoms or are feeling unwell - Prevent a worker from an affected area or who has been in contact with an infected person from entering the construction area/site for 14 days. Preventing a sick worker from entering the construction area/site, referring them to local health facilities if necessary or requiring them to isolate at home for 14 days. (3) Communication and stakeholder engagement plan (CSEP) 3.1 Risks due to lack of • Throughout the construction phase, the Contractor will inform the HCF owner, Same as (1.1) Same as (1.1) communication on the PHO/DHO, local authorities and community on the construction plan and schedule and above above construction plan before update them on a monthly basis. The proposed plan will be adjusted and finalized as agreed with the HCF managers and local authorities. 3.2 Risks due to mis- • The Contractor will assign the focal point to be responsible for timely and effective Same as (1.1) Same as (1.1) communications and lack of communication with the HCF manager, PiSECCON, PCO, local authorities, local above above communication and feedback communities, and general public on the implementation of all the subplans established and grievance redress before and during construction, including those related to the IPC on COVID-19. At mechanism (GRM). least 1 monthly meeting will be conducted. • The Contractor will establish a feedback or GRM and will take immediate actions to respond to any compliant and/or request. Record will be properly kept and included in the progress report. • Both PiSECCON and contractor will assign the focal points responsible for ensuring close coordination and cooperation among key parties as well as with PCO throughout the construction period. PiSECCON and PCO will include GRM record in the progress report to be submitted to WB. • PiSECCON will also ensure that the Contractor provides the contact details including the phone numbers of the Contractor’s ES specialist responsible for supervision of construction compliance by all staff and workers and serving as focal point to handle and report on possible work related incidents and grievances (particularly those related to community health and safety SEA, GBV and VAC) that may be raised by the local villagers; staff, patients, and visitors of the hospital, and b) PiSECCON’s focal point or staff appointed to supervise all the contractor’s workers performance, behaviors and compliance with the social code of conduct and to handle with any contract related 105 grievance and incidents (particularly those related to occupational health and safety, SEA, GBV and VAC). 3.3 Risks due to inadequate • The Contractor will recruit an experienced ES specialist to work on ES and safety related Same as (1.1) Same as (1.1) awareness, knowledge, and issue during the construction period. This ES specialist can also be assigned as the focal above above capacity of Contractor’s staff point for addressing the ES issues during operation of HCF. and workers on ES issues • The focal points will have adequate knowledge on the ES requirements and specific training will be provided by PiSECCON. (4) Site clearance and safety plan –including earth excavation and use of soil materials 4.1 Vegetation clearance for • The Contractor will minimize tree cutting at the construction site. Any large tree Same as (1.1) Same as (1.1) construction. cutting will be made only with agreement with the HCF manager and approved by above above PiSECCON. 4.2 Risk from not proper • The excavated soil will be properly disposed of at an authorized location and after Same as (1.1) Same as (1.1) disposed of spoil and other testing will be used for architecture improvement at the construction site and/or above above materials. building up a useful ground for future use of the local community. 4.3 Risk on cultural heritage • The Contractor is required to follow the “chance find procedures” described in Same as (1.1) Same as (1.1) Attachment 4 – in case underground archeological sites, cultural relics and artifacts, above above etc., are found during earth excavation. • The Contractor will minimize potential impacts on local cultural sites (such as temple, etc.) through the implementation of the traffic and road safety plan (TRSP) described in subplan 9 below. 4.4 Resource efficiency issues, • Most of the construction material will be purchased from the local market. Same as (1.1) Same as (1.1) including raw materials, water • Electricity and water supply will be connected to the existing HCF with permission of above above and energy use. the HCF manager and the use will be strictly monitored for the construction purpose. • Need for taking materials from borrow pits and quarries is not expected. However, if soil from borrow pits or quarries is required, the Contractor will identify the proposed site for approval by PiSECCON. The sites will be publicly owned and has to be properly closed after supplying. For private land, a record on agreement with the land owner will be obtained. This is to make sure that there will no encroachment on any person's land that causes to any conflict with the land owner. • PiSECCON will supervise and monitor the use of resources, water and energy in this case. 4.5 Safety risks on patients and • Before construction begins, the Contractor will complete installation of safety wall/fence Same as (1.1) Same as (1.1) visitors due to ongoing with adequate warning signs (visible during day and night). To ensure safety of the above above construction activities. HCF’s patients and visitors. • PiSECCON will approve the plan and monitor the implementation regularly. 106 4.6 Risks due to UXO • PiSECCON will obtain from National Regulatory Agency (NRA) an UXO Same as (1.1) Same as (1.1) contamination and clearance map. above above • If map indicates with UXO contamination and not having cleared, PiSECCON will engage a qualify firm for screening and clearing. • Obtain UXO clearance certificate from NRA after clearance. • If map indicates with No UXO contamination or UXO clearance has been done earlier in the area, obtain a letter or certificate from NRA or related agencies as appropriate. • In corroboration with PCO, PiSECCON will ensure adequate budget from the contingency fund for UXO clearance. (5) Demolition of existing building and structure. For the proposed HCF in Sekong Provincial Hospital, 8 small old buildings will be demolished to give space for construction of new buildings. 5.1 Safety risk due to the • It is estimated that about 1,200 m3 of demolition debris and spoil will be generated. These Same as (1.1) Same as (1.1) demolition of buildings wastes will be disposed of at the provincial sanitary landfill located about 35 km from above above (accident/injury, noise, dust, the proposed HCF. vibration, air emission and • Collect and dispose of asbestos containing materials (ACM) in according to the transportation of debris and other guideline. Training to workers on proper handling of ACM may be necessary materials etc.), and disposal of • Cover truck to prevent debris from falling off the truck which may case accident to people nearby, or damage demolition debris and other • During the demolition of old building and construction of new building, the mesh/plastic possible asbestos-containing sheet will be used to cover the construction sites. materials (ACM). • Spray water at least two times a day at the construction area to prevent dust generation and air pollution in the hospital area • During demolition work, the Contractor will ensure with all compliance while PiSECCON will supervise and monitor the implementation of required actions. 5.2 Risks due to lack of • The Contractor to establish and maintain close communication and consultation with Same as (1.1) Same as (1.1) information on demolition work related agencies and local authorities. above above which can pose an accidents to local authorities and local community during the demolition and transportation of demolition debris and materials (6) Construction management and pollution control (CMPC) 107 6.1 Risks due to use of • Before construction, the Contractor will ensure that their machineries are in a good Same as (1.1) Same as (1.1) construction machinery, solid condition and ready for construction activities, prepare for a periodical maintenance of above above waste management at the machines and equipment to reduce generation of dust and other air pollution, noise, and construction site, construction vibration during construction as well as those from workers and transportation of wastewater, noise, vibration, construction materials. Install a safety fence/wall with adequate and proper warning signs dust, and other air emissions (visible for day and night) between the construction site and existing HCFs. Efforts will management. be made to install noise barrier and minimize vibration, dust, and air pollution during execution of the works as much as possible. The waste water from the construction site will be treated by septic tank before discharge to the public drain. • The following actions will be strictly prohibited for proposed construction: o Use of ACM (asbestos-containing materials) for new construction and structures; o Night construction is prohibited (the construction activities will be carried out during day time only); o Risky driving, unnecessary use of horn, drinking in worker camp, creation of noises, and the use of toilets and HCF facilities by the Contractor staff and workers; o Open burning or burial of solid wastes at the construction site o Creation of any fire within the construction site including worker-camp; o Disposal of any wastes (organic, hazardous, and toxic) in an unauthorized disposal sites; and o Disposal of any debris or construction material/paint in environmentally sensitive areas (including watercourse). • PiSECCON will review and approve any E&S management plan and supervise and monitor the implementation and Contractor’s performance. 6.2 Risk of non-compliance with • The Contractor is responsible for compliance with relevant national legislation with Same as (1.1) Same as (1.1) Government and local respect to ambient air quality, noise and vibration. above above regulations related to environmental quality standards • During construction, the Contractor will strictly follow up environmental during construction. management plans approved by PiSECCON. • All machines to be used will be new and/or properly maintained. • The Contractor will avoid carrying out construction activities generating high level of noise and minimize disturbances for patients, staff and surrounding community as much as possible. 108 • The Contractor will implement dust suppression measures (e.g. water paths, covering of material stockpiles, etc.) as required. Materials used will be covered and secured properly during transportation to prevent scattering of soil, sand, materials, or generating dust. Exposed soil and material stockpiles will be protected against wind erosion. • The Contractor will ensure onsite latrine be properly operated and maintained to collect and dispose wastewater through the septic tank from those who do the works. (7) Waste and worker camp management (WWCM) - it is expected that a small worker camp will be established within the existing hospital premise. 7.1 Risks and impacts related to • The Contractor will properly manage solid waste in accordance with site specific Same as (1.1) Same as (1.1) waste management at work site environmental and social management plan including those related to toxic wastes and above above and worker camp including hazardous substance. The Contractor is required to comply with local requirements on onsite waste storage and solid waste management and open burning of waste in the construction site is not management and offsite allowed. The onsite solid waste control (storage, provision of bins, site clean-up, bin disposal. clean-out schedule, etc.) including waste transportation, and offsite disposal procedure should be established. Potential infection waste from COVID-19 (such as used masks, PPEs, etc.) will be treated and managed properly. • The Contractor with PiSECCON supervision will ensure compliance with site specific environmental and social management plan. Contractor’s staff and workers will use litter bins, containers and waste collection facilities provided for at the construction site and worker camps during works. The Contractor may store solid waste temporarily on site in a designated place prior to off-site transportation and disposal through a licensed waste collector. All wastes will be disposed of at designated place identified and approved by local authority. • Recyclable materials such as wooden plates for trench works, steel, scaffolding material, site holding, packaging material, etc. can be segregated and collected on-site from other waste sources for reuse or recycle (sale). However, this action will be properly planned (if necessary) and organized to ensure safety and security of the construction site. 7.2 Risks and impacts related to • During construction, the Contractor with PiSECCON supervision will strictly follow the Same as (1.1) Same as (1.1) use and disposal of fuel, oils, site specific environmental and social management plan and identify/confirm specific above above lubricant including the use of measures to manage use and disposal of fuel, oils, lubricant and other hazardous ACM materials as appropriate. These materials will be stalled in the storage with concrete floor and roof. • The use of ACM for construction materials is prohibited. 109 7.3 Risks during decommission •The Contractor will ensure proper site Decommissioning or Site Closure before leaving Same as (1.1) Same as (1.1) of the construction site due to the construction site. above above unclean and remaining wastes • Ensure safety for workers and people in the surrounding area during implementation of decommissioning activities, continue to apply road safety measures, clearance of construction waste and other facilities as part of the workers’ camp and restore the surrounding area back to pre-construction condition, and safe disconnection of water supply electricity etc. • PiSECCON will ensure compliance with the above actions before construction is completed and the Contractor leaves the site. (8) Occupational health and safety (OHS) and Community Health and Safety (CHS) –including EPR 8.1 Risk due to health and safety • Before construction, the Contractor will ensure to provide the workers with PPEs Same as (1.1) Same as (1.1) of Contractor’s staff and and ensure that the staff and workers apply them effectively. The Contractor will above above workers including preparation of comply with all national and good practice regulations regarding workers’ safety. an emergency preparedness and The contractor will develop a simple Emergency Preparedness and Response response (EPR) plan identifying actions to be undertaken when Contractor’s workers and/or staff are ill, injured, and/or infected by COVID-19 contagion (also see (3) above). • The Contractor as appropriate will (a) prepare and implement a simple action plan to cope with risk and emergency (e.g., fire, earthquake, floods, COVID-19 outbreak); (b) have or receive minimum required training on occupational and community health and safety regulations and use of personal protective equipment as well as worker’s Codes of Conduct (see Annex 3); and (d) provide safety measures as appropriate during works such as installation of fences, fire extinguishers, first aid kits, restricted access zones, warning signs, overhead protection against falling debris, lighting system to protect hospital staff and patients against construction risks, etc. • During construction, the Contractor will strictly implement the OHS measure while Same as (1.1) Same as (1.1) PiSECCON will supervise and monitor contractor performance. above above 8.2 Risk of accident and needs • The Contractor will report all accidents to PiSECCON so they can be reported to PCO Same as (1.1) Same as (1.1) for compensation. and to the WB. above above • The Contractor will be responsible for the illness or injury of staff and workers when they are on duty and pay compensation as required by laws and/or regulations. 8.3 Risk on Community Health • The Contractor will adopt community health and safety measures to manage and mitigate Same as (1.1) Same as (1.1) and Safety (CHS) risks associated with infectious and communicable (waste, air and water borne) diseases above above 110 and adverse impacts on health staff, patients, their relatives and surrounding local communities. (9) Traffic and road safety management –TRSM 9.1 Transportation of • The Contractor will adopt measures on Transportation and Road Safety Management Same as (1.1) Same as (1.1) construction materials can (TRSM) to avoid local traffic congestion, speed limit for all truck and other vehicles used above above increase risks on local traffic for construction, and other specific measures to reduce the generation of noise and congestion, road safety, and vibration during transportation as well as installation of appropriate warning signs in damage to public road and other areas with high transportation and road safety risks such as school and residential areas facilities to be affected by transportation of construction materials. • As indicated above, trucks carrying construction materials will be covered to prevent spillage of soil, sand, and other construction materials; truck overloading and unnecessary use of horn will not be allowed; speed limit will be strictly followed by all construction trucks and vehicles. • All drivers will have driving license and they are informed and/or trained to be aware of these obligations. • The Contractor will ensure transport and road safety and be responsible for all accidents Same as (1.1) Same as (1.1) and public damages that may occur following the Government and local regulations. above above • If found guilty, the Contractor will pay compensation for public and private damages that may occur as required by Government regulations and/or complete rehabilitation of public roads and/or facilities that are damaged from the incidents related to transportation of construction materials and wastes. • PiSECCON will supervise and monitor the contractor performance. 9.2 Risks to the HCF patient and • The Contractor will install appropriate warning signs (visible day and night) as well as Same as (1.1) Same as (1.1) visitors and local communities ensure effective implementation of all the above actions (IPC, CSEP, CMPC, WWPC, above above due to driving behavior and TRSM). • PiSECCON will work closely with local police and local communities on this aspect. 9.3 Risks related to traffic and • Any serious accident related to workers, local communities, and/or other key Same as (1.1) Same as (1.1) road accidents stakeholders, especially the hospital staff, patients, and/or visitors that occur due to the above above construction activities will be reported to WB within 24 hours. Fatal accident will require extensive investigation on the root cause and agreement on the mitigation measures and follow-up actions. 111 Attachment 1. Infection Prevention and Control Measures This attachment provides simple guidance on hand hygiene procedures and application of PPEs taking into account GOL regulations and policy guidance to provide appropriate knowledge and understanding on the nature of COVID-19 infections and prevention. This attachment should be adjusted as appropriate. 1. Contractor and workers should perform hand hygiene, when arriving at work and before leaving work, as well as before eating and after using the toilet/ latrine to prevent possible infection with COVID-19. Additionally, for anyone who is working, visiting the area for example relevant GOL officers who come to monitor the works shall follow the same Infection Prevention and Control Procedure. This ensures that all processes are integrated with the control of the outbreak of COVID-19. 2. Respiratory hygiene and cough etiquette is a standard precaution that should be applied by Contractor and workers, visitors to contain respiratory secretions (e.g. when coughing, sneezing…) to avoid spreading respiratory infections. 112 3. Contractor should promote respiratory hygiene and cough etiquette by: • Educating workers and visitors on the importance of containing respiratory droplet/ aerosol and secretions to prevent the transmission of infectious disease (e.g. influenza, tuberculosis, bacterial pneumonia …). • Posting signs informing that workers and visitor with acute febrile respiratory illness use respiratory hygiene/cough etiquette (e.g. poster). • Prepare equipment in triage area for workers and visitor to apply respiratory hygiene. • Provide alcohol for hand sanitizing available for workers and visitors. • Encourage workers and visitors to wear face mask at all time. 113 • Make goggle or face shield available for workers and visitors. 114 Attachment 2. Covid Rapid Assessment Form and Guideline for Preparation of COVID Contingency Plan This attachment comprises Part A and Part B. Part A. COVID-19 Rapid Assessment Form Contract No: ………………………; Location: ………………………………………. District:..................................................; Province:................................................................... 1. General Information of Contractor Contractor Name: Name and Contact Number of Contractor Coordinator responsible for Covid-19 Responses: Contract Starting Date: Contract End Date: 2. COVID-19 Rapid Assessment From Date: To Date: .......................... ........................ No working period during Lockdown:......................... Days ..... ..... Status of construction/civil work on the ground ` On-going as normal ` No working Total staffs/workers/consultants working in the field: ________persons, ______ females Nationality: Lao_________ persons, foreigners __________persons, country of foreigner staffs:____________________________________________________________________________ Total staffs/workers/consultants are living/staying in the work camp: ________persons, ______ females Nationality: Lao_________ persons, foreigners __________persons, country of foreigner staffs:____________________________________________________________________________ Total staffs/workers/consultants are NOT living in the work camp: ________persons, ______ females Nationality: Lao_________ persons, foreigners __________persons, country of foreigner staffs:____________________________________________________________________________ What are the following measures that your company implemented to prevent and control the COVID-19 infections at your work camps and/or work sites? Please mark with “√” where applicable: ` Information dissemination and training on COVID-19 infections (esp. its danger and symptoms and how to avoid, prevent, control and treatment measures) for all staffs/workers/consultants working for ACP; ` Use of information dissemination tools: posters, booklets and speakers; ` Check body temperature for all staffs/workers/consultants before starting working; ` Provide free masks for all staffs/workers/consultants before starting working; ` Provide free hand sanitizers for all staffs/workers/consultants before starting working; ` Provide free soups for all staffs/workers/consultants before starting working; ` Clean or disinfect the work place and worker camps; ` Implement Social Distance at least 1m while working; ` Staff rotation: allow the key staffs/workers for priority tasks/works to limit/avoid many people working at the same time; ` Regularly report and coordinate with PCO and/or PHO/DHO about the COVID-19 infections and prevention and emergency response plans; ` Report to PCO by:______________________________________________________________ ` Others (please specify)__________________________________________________________ What are supports has your company provided to your staffs/workers/consultants throughout the break during the lockdown period? ` No salary during work ` Pay full salary 115 ` Pay 50% of salary ` Pay 30% of salary ` Other supports (please specify)___________________________________________________ How many of your staffs/workers/consultants working at the field have the following symptoms? ` Had COVID-19 symptoms ____________persons ` Came from oversee/other provinces and quarantined for 14 days____________ persons ` Infected cases ______persons and treated at hospital (name)____________________________ ` For the infected case, fully recovered and discharged _________ persons, being treated ___________ persons Does your company have an Emergency Response Plan in case of your staffs/workers/consultants has covid-19 symptoms and/or get infection? Please mark with “√” where applicable: ` Provide quarantine place with basic supporting facilities; ` Immediately stop working with paid leave; ` Call the government Covid-19 agency (please specify the name):________________________________; ` COVID-19 hotline ___________landline number_______________, Mobile number__________________; ` Quarantine all people contacted with infected person; ` Clean and disinfect all things, areas and places where infected person uses and goes; ` Pay all bills for testing and treatment; ` Disclose and report to all local communities and PCO about information of infected staffs such as people contacted and work places; ` Other supports (please specify)___________________________________________________ What are supports your company needs from the Project Owner and the World Bank? ` Contract amendment and extension for _____________________months ` Others (please specify)________________________________________________________________ Information provided by Contractor: Information reviewed by Signature: Signature: Full name: Full name: Position: Position: Date: Date: Part B. Contingency Plan for Response to COVID-19 1. In a situation when there is a spread of COVID-19, contractor has to apply and comply with the government guidelines launched in line with WHO. Additional suggestions which are adapted from WBG Response to COVID-19 Advisory note on Contingency Planning for Existing Operations dated March 16, 2020, and WBG Safeguard Interim Note on COVID-19 Considerations in Construction/Civil Works Projects, April, 2020. 2. It is worth noting that the WBG Response to COVID-19 Advisory note and Interim Note may be updated from time to time. Where there is a conflict with government or WHO guideline, the government or WHO guideline prevail. (a) Preparing for Covid-19 • Contractor’s senior manager or project manager should inform PCO and/or PHO/DHO details of the preparations being made on site. PCO and/or PHO/DHO will, as necessary assist the projects with these preparations. The senior manager should be taking the advice of their healthcare team and their health and safety specialists in preparing the site, although the PCO, and/or PHO/DHO may also need to assist, for 116 example with coordinating responses and/or connecting project sites with national/local healthcare official and/or specialists. • Contractor should put in place measures to minimize the chances and contain the spread of the virus as a result of the movement of workers, ensure their sites are prepared for an outbreak, and develop and practice contingency plans so that personnel know what to do if an outbreak occurs and how treatment will be provided. These preparation measures should be communicated not only to the workforce but also the local community, to reassure them that the movement of staff is controlled, and to ensure that stigma or discrimination is reduced in the event of an outbreak. (b) Movement of Staff • Movement of staff can increase the risk of transmission of Covid-19 to a work site and the local community. Overseas, international and transient workers should adhere to government requirements and guidelines with respect to Covid-19 when travelling to or from worksites. • Workers coming from or passing through countries/regions with cases of the virus12 (a) Should not return if displaying symptoms and (b) Should self-isolate for 14 days following their return. Self-Isolation arrangements: For self-isolation, the following actions should be considered (as appropriate): • Workers should be provided with a single room that is well-ventilated (i.e., with open windows and an open door). If a single room is not available for each worker, adequate space should be provided to maintain a distance of at least 2meters and a curtain to separate workers sharing a room. Men and women should not share a room. A dedicated bathroom should be provided for the isolation facilities and there should be separate bathroom facilities for men and women. • Workers in isolation should limit their movements in areas which are also used by unaffected workers shared areas), and should avoid using these areas when unaffected workers are present. Where workers in isolation need to use shared spaces (such as kitchens/canteens), arrangements should be made for cleaning prior to and after their use of the facilities. The number of staff involved in caring for those in isolation, including providing food and water, should be kept to a minimum and appropriate Personal Protection Equipment (PPE) should be used by those staff. • At a minimum, isolation areas should be cleaned daily and healthcare professionals should visit workers in the isolation areas daily. Cleaners and healthcare professionals should wear appropriate PPE and ensure good hygiene when visiting workers in isolation. Further information is provided by WHO in Home care for patients with suspected novel coronavirus (COVID-19) • Visitors should not be allowed until the worker has shown no signs and symptoms for 14 days. (c) Preparing for an Outbreak 3. Medical staff at the facilities or medical service personal for the facilities should be trained and be kept up to date on Country and WHO advice (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical- guidance) and recommendations on Covid-19. They should take stock of the equipment 12 WHO also updates information on countries reporting Covid-19 infection 117 and medicines that are present on site and ensure that there are good supplies of any necessary treatments, including paracetamol/acetaminophen and other medicine in line with country and WHO guideline. 4. The following measures should be considered (as appropriate): • Ensure medical facilities or camp site are stocked with adequate supplies of medical Personal Protective Equipment (PPE), as a minimum: (a) Gowns, aprons; (b) Medical masks and some respirators (N95 or FFP2); (c) Gloves; and (d) Eye protection (goggles or face screens). • Cleaners also need to be provided with PPE and disinfectant. Minimum PPE to be used when cleaning areas that have been or suspected to have been contaminated with Covid-19 are: (a) Gowns, aprons; (b) Medical masks; (c) Gloves; (d) Eye protection (goggles or face screens); and (e) Boots or closed work shoes. Cleaners should be trained in how to safely put on and use PPE by medical staff, in necessary hygiene (including hand washing) prior to, during and post cleaning duties, and in waste control (including for used PPE and cleaning materials). • The medical staff should run awareness campaigns, training and arrange for appropriate posters, signs and advisory notices to be posted on site to advise workers on how to minimize the spread of the disease, including: (a) to self-isolate if they feel ill or think they may have had contact with the virus, and to alert medical staff; (b) to regularly wash hands thoroughly with soap and water – many times per day; (c) how to avoid disease spread when coughing/sneezing (cough sneeze in crook of elbow or in a tissue that is immediately thrown away), and not to spit; and (d) to keep at least 2meters or more away from colleagues. • Hand washing stations should be set up at key places throughout site, including at entrances/exits to work areas, wherever there is a toilet, canteen/food and drinking water, or sleeping accommodation, at waste stations, at stores and at communal facilities. Each should have a supply of clean water, liquid soap and paper towels (for hand drying), with a closed waste bin (for used paper towels) that is regularly emptied and disposed off following government guideline. • Where wash stations cannot be provided (for example at remote locations), alcohol- based hand rub should be provided. • Enhanced cleaning arrangements should be put in place, to include regular and deep cleaning using disinfectant of catering facilities/canteens/food/drink facilities, latrines/toilets/showers, communal areas, including door handles, floors and all surfaces that are touched regularly. Worker accommodation will be in good state for keeping clean and hygienic, and for cleaning to minimize spread of infection. • Working methods should be reviewed and changed as necessary to reduce use of PPE, in case supplies of PPE become scarce or hard to obtain. For example, water sprinkling systems at crushers and stock piles should be in good working order, trucks covered, water suppression on site increased and speed limits on haul roads lowered to reduce the need for respiratory (N95) dust masks. (d) Contingency Planning for an Outbreak 5. The contingency plan to be developed by contractor should set out what procedures will be put in place in the event of Covid-19 reaching the site and it should be developed in consultation with national and local healthcare facilities and PCO or PPHO/DHO, to ensure that arrangements are in place for the effective containment, care and treatment of workers who have contracted Covid-19. 118 6. The contingency plan should also consider the response if a significant number of the workforce become ill, when it is likely that access to and from a site will be restricted to avoid spread. The following measures should be considered, as appropriate: • Contingencies should be developed and communicated to the workforce for: (a) Isolation and testing procedures for workers (and those they have been in contact with) that display symptoms; (b) Care and treatment of workers, including where and how this will be provided; and (c) Getting adequate supplies of water, food, medical supplies and cleaning equipment in the event of an outbreak on site, especially should access to the site become restricted or movements of supplies limited. The contingency plan shall be aligned with the government guideline. • Specifically, the plan should set out what will be done if someone is suspected to become ill with Covid-19 at a worksite. The plan should: (a) Set out arrangements for putting the person in a room or area where they are isolated from others in the workplace, limiting the number of people who have contact with the person and contacting the local health authorities; (b) Consider how to identify persons who may be at risk (e.g. due to a pre-existing condition such as diabetes, heart and lung disease, or as a result of older age), and support them, without inviting stigma and discrimination into your workplace; and (c) Consider contingency and business continuity arrangements if there is an outbreak in neighboring communities. • Arrangements for the storage and disposal arrangements for medical waste, which may increase in volume and which can remain infectious for several days (depending upon the material). The support that site medical staff may need, as well as arrangements for transporting (without risk of cross infection) sick workers to intensive care facilities or into the care of national healthcare facilities should be discussed and agreed. • How to maintain worker and community safety on site should works be suspended or illness affect significant numbers of the workforce at any point. It is important that worksite safety measures are reviewed by a safety specialist and implemented prior to work areas being suspended. (e) Communicating the plans 7. In order to reduce the risk of social stigma 13 or discrimination, and to ensure that individuals roles and responsibilities are clear, the preparation measures and contingency plans should be communicated widely. Workers, sub-contractors, suppliers, adjacent communities, and local healthcare authorities should all be made aware of the preparations that have been made. 8. When communicating to the workforce, their roles and responsibilities should be outlined clearly, and the importance for their colleagues, the local communities and their families that the workers follow the plans should be stressed. Workers may need to be reassured that they there will be no retaliation or discrimination if they self-isolate as a result of feeling ill, and also with respect to the compensation or insurance arrangements that are in place. Further guidance on preventing social stigma as a result of Covid-19 is available in WHO guidelines 13 Social stigma in the context of health is the negative association between a person or group of people who share certain characteristics and a specific disease. 119 Attachment 3. Social Code of Conduct (SCOC) Instructions: 1. This Social Code of Conduct (SCOC) is part of the contract documents. Signing of the SCOC form by Contractor manager, staffs, and workers are required. Manager’s Code of Conduct 2. The contractor is committed to ensuring that the project is implemented in such a way which minimizes any negative impacts on the local environment, communities, and its workers. This will be done by respecting the environmental, social, health and safety (ESHS) standards, and ensuring appropriate occupational health and safety (OHS) standards are met. The contractor is also committed to creating and maintaining an environment where children under the age of 18 will be protected, and where sexual abuse and sexual harassment have no place. Improper actions towards children, Violence Against Children (VAC), sexual abuse/harassment, and/or acts of Gender Based Violence (GBV) will not be tolerated by any employee, sub-contractors, supplier, associate, or representative of the company. 3. Staff at all levels have a responsibility to uphold the contractor’s commitment. Contractors need to support and promote the implementation of the SCOC. To that end, staff must adhere to this SCOC and also to sign the Individual Code of Conduct (ICOC). Implementation 4. As follows: a. To ensure maximum effectiveness of the SCOC: (i) Prominently displaying the SCOC in clear view at workers’ camps, offices, and in public areas of the workspace. Examples of areas include waiting, rest and lobby areas of sites, canteen areas and health clinics. (ii) Ensuring all posted and distributed copies of the SCOC are translated into the appropriate language of use in the work site areas as well as for any international staff in their native language. b. Verbally and in writing explain the SCOC to all staff, including in an initial training session. c. Ensure that: (i) All staff sign the ‘Individual Code of Conduct’, including acknowledgment that they have read and agree with the SCOC. (ii) Staff lists and signed copies of the Individual Code of Conduct are provided to the OHS Manager and the MOH Focal Point. (iii) Participate in training and ensure that staff also participate as outlined below. (iv) Put in place a mechanism for staff to: - report concerns on ESHS or OHS compliance; and, - confidentially report GBV incidents through the Grievance Redress Mechanism (GRM) (v) Staff are encouraged to report suspected or actual ESHS, OHS, GBV, VAC issues, emphasizing the staff’s responsibility in compliance with applicable laws and to the best of your abilities, prevent perpetrators of sexual exploitation and abuse from being hired, re-hired or deployed. Use background and criminal reference checks for all employees nor ordinarily resident in the country where the works are taking place. 120 d. Ensure that when engaging in partnership, sub-contractor, supplier or similar agreements, these agreements: (i) Incorporate the ESHS, OHS, GBV, VAC Codes of Conduct as an attachment. (ii) Include the appropriate language requiring such contracting entities and individuals, and their employees and volunteers, to comply with the Individual Codes of Conduct. (iii) Expressly state that the failure of those entities or individuals, as appropriate, to ensure compliance with the ESHS and OHS standards, take preventive measures against GBV and VAC, to investigate allegations thereof, or to take corrective actions when GBV or VAC has occurred, shall not only constitute grounds for sanctions and penalties in accordance with the Individual Codes of Conduct but also termination of agreements to work on or supply the project. e. Provide support and resources to create and disseminate staff training and awareness-raising strategy on GBV, VAC and other issues highlighted in the ESMF. f. Ensure that any GBV or VAC complaint warranting Police action is reported to the Police, MOH and the World Bank immediately. g. Report and act in accordance with the agreed response protocol any suspected or actual acts of GBV or VAC. h. Ensure that any major ESHS or OHS incidents are reported to MOH and the supervision engineer immediately, non-major issues in accordance with the agreed reporting protocol. i. Ensure that children under the age of 18 are not present at the construction site, engaged in any hazardous activities or otherwise employed. Training j. The managers are responsible to: (i) Ensure that staff have a suitable understanding of the ESMF, in particular OHS aspects and COVID-19 prevention, as well as GBV and VAC and are trained as appropriate. Response k. Managers will be required to take appropriate actions to address any ESHS or OHS incidents. l. Regarding GBV: (i) Maintain the confidentiality of all employees who report or (allegedly) perpetrate incidences of GBV (unless a breach of confidentiality is required to protect persons or property from serious harm or where required by law). (ii) If a manager develops concerns or suspicions regarding any form of GBV by one of his/her direct reports, or by an employee working for another contractor on the same work site, s/he is required to report the case using the GRM. (iii) Once a sanction has been determined by the GRM, the relevant manager(s) is/are expected to be personally responsible for ensuring that the measure is effectively enforced, within a maximum timeframe of 14 days from the date on which the decision to sanction was made by the GRM. (iv) If a Manager has a conflict of interest due to personal or familial relationships with the survivor and/or perpetrator, he/she must notify the Company and the GRM. The Company will be required to appoint another manager without a conflict of interest to respond to complaints. (v) Ensure that any GBV issue warranting Police action is reported to the Police, MOH and the World Bank immediately. m. Managers failing address ESHS or OHS incidents or failing to report or comply with the GBV provisions may be subject to disciplinary measures, to be determined and enacted by the Company. Those measures may include: 121 (i) Informal warning; (ii) Formal warning; (iii) Additional Training; (iv) Loss of up to one week's salary; (v) Suspension of employment (without payment of salary), for a minimum period of 1 month up to a maximum of 6 months; (vi) Termination of employment. n. Ultimately, failure to effectively respond to ESHS, OHS, VAC and GBV cases on the work site by the company’s managers may provide grounds for legal actions by authorities. I do hereby acknowledge that I have read the Code of Conduct, do agree to comply with the standards contained therein and understand my roles and responsibilities to prevent and respond to ESHS, OHS, VAC and GBV requirements. I understand that any action inconsistent with this Code of Conduct or failure to act mandated by this Code of Conduct may result in disciplinary action. Signature: _________________________ Printed Name: _________________________ Title: _________________________ Date: _________________________ Individual Code of Conduct (ICOC) for Contractor’s Workers 5. As follows: Instructions: This Individual Code of Conduct should be included in bidding documents for the civil works contractor(s) and in their contracts once hired. I, ______________________________, acknowledge that adhering to environmental, social, health and safety (ESHS) standards, following the project’s occupational health and safety (OHS) requirements, and preventing Violence Against Children (VAC) and Gender Based Violence (GBV) is important. The Contractor considers that failure to follow ESHS and OHS standards, or to partake in activities constituting VAC or GBV—be it on the work site, the work site surroundings, at workers’ camps, or the surrounding communities—constitute acts of gross misconduct and are therefore grounds for sanctions, penalties or potential termination of employment. Prosecution by the Police of those who commit GBV or VAC may be pursued if appropriate. I agree that while working on the project I will: a. Consent to a background check in any place I have worked for more than six months. b. Attend and actively partake in training courses related to ESHS, OHS, COVID-19 prevention, VAC and GBV as requested by my employer. c. Will wear my personal protective equipment (PPE) at all times when at the work site or engaged in project related activities, in particular if related to exposure to COVID- 19. d. Will follow all prevention measures relating to COVID-19, including (i) washing hands with water and soap before and after eating, when entering my work area, after 122 sneezing/coughing, etc.; (ii) sneeze or cough on elbow and/or wash hands after sneezing/coughing; (iii) if feeling unwell or have symptoms of a cold, flu or any respiratory illness, inform manager immediately, stay at home and do not come to work. e. Take all practical steps that are guided by my manager/supervisor to implement the environmental and social management framework (ESMF). f. Implement and follow OHS measures that are guided by my manager/supervisor. g. Adhere to a zero-alcohol policy during work activities, and refrain from the use of narcotics or other substances which can impair faculties at all times. h. Treat women, children (persons under the age of 18), and men with respect regardless of race, color, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. i. Not use language or behavior towards women, children or men that is inappropriate, harassing, abusive, sexually provocative, demeaning or culturally inappropriate. j. Not sexually exploit or abuse project beneficiaries and members of the surrounding communities. k. Not engage in sexual harassment of work personnel and staff —for instance, making unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature is prohibited: i.e. looking somebody up and down; kissing, howling or smacking sounds; hanging around somebody; whistling and catcalls; in some instances, giving personal gifts. l. Not engage in sexual favors —for instance, making promises of favorable treatment (i.e. promotion), threats of unfavorable treatment (i.e. loss of job) or payments in kind or in cash, dependent on sexual acts—or other forms of humiliating, degrading or exploitative behavior. m. Not use prostitution in any form at any time. n. Not participate in sexual contact or activity with children under the age of 18 — including grooming or contact through digital media. Mistaken belief regarding the age of a child is not a defense. Consent from the child is also not a defense or excuse. o. Unless there is the full consent 14 by all parties involved, I will not have sexual interactions with members of the surrounding communities. This includes relationships involving the withholding or promise of actual provision of benefit (monetary or non- monetary) to community members in exchange for sex (including prostitution). Such sexual activity is considered “non-consensual” within the scope of this Code. p. Consider reporting through the GRM or to my manager any suspected or actual GBV by a fellow worker, whether employed by my company or not, or any breaches of this Code of Conduct. With respect to children under the age of 18: a. Bring to the attention of my manager the presence of any children on the construction site or engaged in hazardous activities. 14Consent is defined as the informed choice underlying an individual’s free and voluntary int ention, acceptance or agreement to do something. No consent can be found when such acceptance or agreement is obtained using threats, force or other forms of coercion, abduction, fraud, deception, or misrepresentation. In accordance with the United Nations Convention on the Rights of the Child, the World Bank considers that consent cannot be given by children under the age of 18, even if national legislation of the country into which the Code of Conduct is introduced has a lower age. Mistaken belief regarding the age of the child and consent from the child is not a defense. 123 b. Wherever possible, ensure that another adult is present when working in the proximity of children. c. Not invite unaccompanied children unrelated to my family into my home, unless they are at immediate risk of injury or in physical danger. d. Not use any computers, mobile phones, video and digital cameras or any other medium to exploit or harass children or to access child pornography. e. Refrain from physical punishment or discipline of children. f. No hiring of children for any project activity (no persons under the age of 18). Sanctions I understand that if I breach this Individual Code of Conduct, my employer will take disciplinary action which could include: a. Informal warning; b. Formal warning; c. Additional Training; d. Loss of up to one week’s salary; e. Suspension of employment (without payment of salary), for a minimum period of 1 month up to a maximum of 6 months; f. Termination of employment; g. Report to the Police if warranted. I understand that it is my responsibility to ensure that the environmental, social, health and safety standards are met. That I will adhere to the occupational health and safety management plan. That I will avoid actions or behaviors that could be construed as VAC or GBV. Any such actions will be a breach this Individual Code of Conduct. I do hereby acknowledge that I have read the foregoing Individual Code of Conduct, do agree to comply with the standards contained therein and understand my roles and responsibilities to prevent and respond to ESHS, OHS, VAC and GBV issues. I understand that any action inconsistent with this Individual Code of Conduct or failure to act mandated by this Individual Code of Conduct may result in disciplinary action and may affect my ongoing employment. Signature: _________________________ Printed Name: _________________________ Title: _________________________ Date: _________________________ 124 Attachment 4. Environmental Code of Practice (ECOP) 1. This attachment is part of the contract. It provides a generic technical guidance for preparation of specific measures especially those related to the construction management and pollution control (CMPC) subplan by contractor. The ECOP comprises 3 parts: (1) General provision describing roles and responsibility of contractor, (2) Specific requirements based on the experience and request from consultation with local authorities and communities in Lao PDR, and (3) Works management and monitoring. Part (1): General Provision and Planning Section (1.1) Contractor responsibility 2. The Contractor is responsible for making best effort to reduce and mitigate the potential negative impacts on local environment and local resident including making compensation payment for all damages that may occur. Contractor performance will be closely supervised and monitored by a qualified field engineer as well as periodic monitored by a qualified consultant, mass organizations, or local communities to be assigned by the HCF owner. Compliance with ECOP is required throughout the construction works period. 3. For clarity, the term “works” and/or “construction” in this document includes all site preparation, demolition, spoil disposal, materials and waste removal and all related engineering and construction activities. Section (1.2) Non-compliance reporting procedures 4. The Contractor (and its subcontractors if any) must comply with the ESCOP. To ensure that necessary action has been undertaken and that steps to avoid adverse impacts and/or reoccurrence have been implemented, the Contractor must advise the HCF owner within 24 hours of any serious incidents of non-compliance with the ESCOP that may have serious consequence. In the event of working practices being deemed dangerous either by the HCF owner, the local authorities, or the other concerned agencies, immediate remedial action must be taken by the Contractor. The Contractor must keep records of any incidents and any ameliorative action taken. The records on non-compliance that could be practically addressed (not cause serious impacts) will be reported to the HCF owner on a monthly basis. 5. The Contractor will be responsible for dealing with any reports/grievance forwarded by the HCF owner, Police, or other agencies (by following instruction from the Project Implementing Entity (PIE)’s representative as appropriate) as soon as practicable, preferably within one hour but always within 24 hours of receipt by either the Contractor. The Construction supervision company (CSC) will monitor and ensure that the Contractor has taken appropriate action. Where appropriate, approval remedial actions may require an agreement from the local authorities and/or other Government agencies. Procedures should be put in place to ensure, as far as is reasonably practical, that necessary actions can be undertaken to avoid recurrence and/or serious damage. Section (1.3) Liaising with local authorities and the public 6. Prior to the commencement of project investment activities and throughout the construction duration, the Contractor will work closely with the local authorities and other agencies to ensure full compliance with Government regulations including those related to life 125 and fire safety (L&FS) risk assessment and management and will also provide adequate information on the Project to the general public, especially those that may cause public safety, nuisance, and sensitive areas and the locations of storage and special handling areas. The Contractor will provide information and reporting telephone “Hot Line” staffed at all times during working hours. Section (1.4) Community relations 7. The Contractor will assign one community-relation personnel, who will be focused on engaging with the community to provide appropriate information on work contract and workplan/schedule and to be the first line of response to resolve issues of concern and grievances that may be raised by the local communities and project affected people. Contractor will take reasonable steps to engage with vulnerable groups of local residents such as people of ethnic minority backgrounds, women and residents with disabilities (or other priority groups as appropriate), who may be differentially affected by construction impacts. 8. The Contractor will ensure that local residents nearby the construction sites will be informed in advance of works taking place, including the estimated duration and contact detail of community relation staff who will be working with the local communities, health staff, patients and visitors to the hospital. In the case of work required in response to an emergency, local residents shall be advised as soon as reasonably practicable that emergency work is taking place. Potentially affected residents will also be notified of the ‘Hotline’ number, which will operate during working hours. The “Hotline” will be maintained to handle enquiries regarding construction activities from the general public as well as to act as a first point of contact and information in the case of any emergency. All calls will be logged, together with the responses given and the callers' concerns action and a response provided promptly. The Hotline will be widely advertised and displayed on site signboards. 9. The Contractor will respond quickly to emergencies, complaints or other contacts made via the ‘Hotline’ or any other recognized means and liaise closely with the emergency services, local authority officers and other agencies (based on established contacts) who may be involved in incidents or emergency situations. 10. The Contractor will manage the work sites, work camps, and workers in a way that is acceptable to local residents and will not create any social impacts due to workers. Any construction workers, office staff, Contractor’s employees, or any other person related to the Project found violating the “prohibitions” activities listed in Section (1.7) below may be subject to disciplinary actions that can range from a simple reprimand to termination of his/her employment depending on the seriousness of the violation. Section (1.5) Implementation of the Environmental Health and Safety (EHS) guideline 11. In line with WB safeguard policy, the Contractor is required to comply with the Environment, Health, and Safety (EHS) guidelines established for the project investment with financial support from the WB group (WBG). The EHS provides general guidance on the pollution prevention and abatement measures and workplace and community health and safety guidelines that are normally acceptable in WB-supported projects, particularly in cases where the country does not have standards, or when its standards fall significantly short of international or industry-wide norms. The EHS are divided in two parts: general guidelines 126 on health and safety and pollution prevention and abatement, including general standards for air and water quality, and a set of sector-specific guidelines for various types of development projects. 12. For the HCF to be constructed, the Contractor will prepare an EHS Plan with an aim to identify the potential impacts and to develop a mechanism for a better management of the environmental health and safety of project activities during construction. The EHS Plan will be incorporated into the standard operation procedures (SOP) of the contractor. At a minimum the following EHS rules will be strictly followed: Site EHS Rules: • EHS orientation sessions before starting work; • Wearing of personal protective equipment (gloves, helmets, safety shoes, dungarees, goggles etc); • Follow the messages and instructions displayed on EHS notice boards installed on site; • Promptly reporting all accidents to the concerned authority; • Maintain appropriate barricades as required; • Vehicles must be driven at a safe speed, observing speed limits of 30 Km/h and designated routes as mentioned in Contractor’s Mobility Map; • Drivers must have a valid driving license for the class of vehicle they are operating; • Vehicles shall only be parked in designated parking areas; and • Mine clearance of the project investment area. Health and Hygiene: The measures should include: • Provision of adequate medical facilities to the staff; • Provision of hygienic food to the employees; • Provision of cooling and heating facilities to the staff; • Provision of drainage, sewerage and septic tanks in camp area; • Provision of handwashing or hand sanitizing facilities; • Compliance with COVID-19 measures in-country. Security: Security measures should include: • Regular attendance and a controlled time keeping of all employees; • Restriction of un-authorized persons to the residential and work areas; • Restriction of carrying weapons and control of hunting by employees; and • Provision of boundary walls/ fences with proper exits to the camp. Section (1.6) Implementation of “Chance Find” Procedures 13. If the Contractor discovers archeological sites, historical sites, remains and objects, including graveyards and/or individual graves during excavation or construction “chance find” the Contractor will carry out the following steps: • Stop the construction activities in the area of the chance find; 127 • Delineate the discovered site or area; • Secure the site to prevent any damage or loss of removable objects. In cases of removable antiquities or sensitive remains, a night guard shall be arranged until the responsible local authorities or the National Culture Administration take over; • Notify the project engineer, supervisor, and/or the project owner (PCO/DPC and/or PHO) who in turn will notify the responsible local authorities and the provincial Culture Department immediately (within 24 hours or less); • Responsible local authorities and the provincial Culture Department will be in charge of protecting and preserving the site before deciding on subsequent appropriate procedures. This would require a preliminary evaluation of the findings to be performed by the archaeologists of National Culture Administration. The significance and importance of the findings should be assessed according to the various criteria relevant to cultural heritage; those include the aesthetic, historic, scientific or research, social and economic values; • Decisions on how to handle the finding shall be taken by the responsible authorities and the provincial Culture Department. This could include changes in the layout (such as when finding an irremovable remain of cultural or archaeological importance) conservation, preservation, restoration and salvage; • Implementation for the authority decision concerning the management of the finding shall be communicated in writing by relevant local authorities; and • Construction work could resume only after permission is given from the responsible local authorities or the provincial Culture Department concerning safeguard of the heritage. Section (1.7) Prohibitions 14. The following activities are prohibited during the execution of works contract: • Use of asbestos-containing material for construction. Demolition of existing buildings will be carefully made to ensure safety of workers and general public during the demolition and disposal of any asbestos-containing materials such as asbestos-cement wall and ceiling; • Cutting of trees for any reason outside the approved construction area; Hunting, fishing, wildlife capture, or plant collection; Buying of wild animals for food; Having caged wild animals (especially birds) in camps; Poaching of any description; Explosive and chemical fishing; Disturbance to anything with architectural or historical value; • Building of fires; Use of unapproved toxic materials, including lead-based paints, asbestos, etc.; Use of firearms (except authorized security guards); Use of alcohol by workers in office hours; Driving in an unsafe manner in local roads; • Washing cars or machinery in streams or creeks; Maintenance (change of oils and filters) of cars and equipment outside authorized areas; Creating nuisances and disturbances in or near communities; Disposing garbage in unauthorized places; Indiscriminate disposal of rubbish or construction wastes; Littering the site; Spillage of potential pollutants, such as petroleum products; Collection of 128 firewood; Urinating or defecating outside the designated facilities; and Burning of wastes and/or cleared vegetation. Part (2) Specific Requirements 15. To be responsive to concerns observed and/or expressed by local authorities and communities, the Contractor will be responsible to comply with, but not limited to, the followings: • The Contractor will install the Work Camp on areas far enough from water points, houses and sensitive areas in consultation with the local authority and local community. Good quality of sanitary system and equipment should be installed in the Work Camp. • The Contractor will manage all activities in compliance with GOL laws, rules and other permits related to site construction regulations (what is allowed and not allowed on work sites), and will protect public properties. Degradation and demolition of private properties will be avoided. Paying compensation for damage to the public facilities and/or private property will be required. The Contractor will inform the IA on issue and/or damages that may unexpectedly occur. • The Contractor is responsible for protection of local environment against dust, air, noise, vibration, exhaust fuels and oils, and other solid residues generated from the work sites. The Contractor will manage waste properly and do not burn them on site and will also provide proper storage for construction materials, organize parking and displacements of machines in the site. Used oil and construction waste materials must be well kept and transported to sanitary landfill for further properly disposal and adequate waste disposal and sanitation services will be provided at the construction site next to the generated areas. In order to protect soil, surface and ground water the Contractor will avoid any wastewater discharge, oil spi1l and discharge of any type of pollutants on soils, in surface or ground waters, in sewers and drainage ditches. Compensation measures may be required. • The Contractor will be responsible for maintaining good hygiene, safety, and security of the work sites, including protection of and health and safety of staff and workers. The Contractor will prevent standing water in open construction pits, quarries or fill areas to avoid potential contamination of the water table and the development of a habitat for disease-carrying vectors and insects. Safe and sustainable construction materials and construction method should be used. • The Contractor will comply with COVID-19 measures as determined by authorities. • The Contractor will use a quarry of materials according to the regulations and compensate by planting of trees in case of deforestation or tree felling. When possible, the Contractor should develop maintenance and reclamation plans, protect soil surfaces during construction and re-vegetate or physically stabilize eligible surfaces, preserve existing fauna and flora and preserve natural habitats along streams, steep slopes, and ecologically sensitive areas. 129 • The Contractor will take serious actions to control dust by using water or through other means and the construction site will be cleaned on a daily basis. • The Contractor will (a) inform local authority on construction plan and schedule, (b) manage local traffic effectively, and (c) ensure traffic access and road safety of local residents and road users during construction works. Speed limit at work sites and community area will be applied to all construction vehicles and trucks. All vehicles and their drivers must be identified and registered and the drivers are properly trained. • The Contractor will install signs and signals of works, ensure no blockage of access to households during construction and/or provide alternative access, provide footbridges and access of neighbours and endure construction of proper drainage on the site. • The Contractor will respect the cultural sites, ensure security and privacy of women and households in close proximity to the Work Camps. Part (3) Works Management and Monitoring 16. This section provides an example for typical measures for physical works. Contractor’s performance during implementation of works will be supervised and monitored by the CSC (PiSECCON). (a) Management and Monitoring of Project Works # Activities Mitigation measures Monitoring causing indicators impacts 1 Establishment • Ensure that the sites for campsite are approved Location of the work and operation by the Project and local authority; Selection of camp should be of worker the camp sites should be made through shown in the camps, tripartite consultation including community, alignment sheet. Contractor, and the subproject representative. • Ensure that basic camp facilities are provided including security, septic tanks, latrines, safe No complaints from local authorities and water supply, mosquito net, blanket, safe paths, local residents due to fire prevention equipment, etc. location and activities • Ensure that camp facilities comply with of the worker camps. COVID-19 guidelines on physical distancing, etc. • Ensure that (a) washing areas, demarcated and Safe and comfortable water from washing areas and kitchen is living of staff and released in sumps, (b) septic tanks of workers appropriate design have been used for sewage treatment and outlets are released into sumps and must not create a pond of stagnant water, and (c) the latrines, septic tanks, and sumps are built at a safe distance from water body, stream, or dry streambed, and the sump bottom is above the groundwater level. 130 # Activities Mitigation measures Monitoring causing indicators impacts 2 Establishment • Ensure that the locations are far away from Proper management and operation residential areas and take actions to mitigate of the site and no of construction dust, noise, vibration, water pollution, waste, complaints from local materials and etc. authorities and equipment residents yards and access roads 3 Disposal of • Recycle metallic, glass waste; burry organic waste generated waste in impervious pit covered with soil. No health issue from the camp • Ensure that waste material is properly disposed occurred of in a manner that does not affect the natural drainage. 4 Access • The moving machinery should remain within tracks/haulage the subproject boundary. routs • Ensure that the access tracks, which are prone to dust emissions and disturbance to local No complaints from resident are managed by water spraying daily local residents and the areas sensitive to noise and vibration regarding dust, noise, are managed through enforcement of speed vibration, road safety, limit control. and the usage of the tracks/access roads • After completion of construction work all the damaged roads / tracks will be restored by the Contractor, as it is Contractor’s obligations. Ensure that surface run-off controls are installed and maintained to minimize erosion. • Restriction on movement of Contractor’s vehicles on designation routes; deploy traffic man at the village to control the traffic as needed. 5 Hiring labors • Hiring of workers from the local communities Number of local particularly as many as possible. workers at the skilled workers • Contractor to adopt and observe the Labor worksite. from outside of Management Procedures to ensure that all the locality different categories of workers will be managed and treated in line with the national labor law and ESS2. The LMP will also include a dedicated labor grievance mechanism for direct and contracted workers to compile grievances from community workers. • Under the LMP, no child labor/workers under the age of 18 shall be hired and allowed to work by the contractor. 131 # Activities Mitigation measures Monitoring causing indicators impacts 6 Worker safety • Provide protective clothing and equipment for Safe working and hygienic workers especially those handling hazardous conditions conditions materials, (helmets, adequate footwear) for concrete works (long boots, gloves), for welders (protective screen, gloves dungaree), etc. Provide PPE for COVID prevention as needed following local guidelines. Provide handwashing and/or hand sanitizing facilities. 7 Water for staff • Provide adequate and safe water for Water tanker and and workers consumption at sites and work camp. pump by the consumption Contractor and construction 8 Interruption of • Inform residents and provide water supply as No complaint from water supply needed. residents 9 Social issues • Ensure that conflicts with local power holders No social conflicts and local communities are avoided. due to the subproject • Ensure that focus group meetings are activities and/or conducted with both men and women to workers. identify any project related and other issues related to the subproject implementation. • Ensure that COVID-19 preventative measures such as physical distancing measures are followed. • Contractor will adopt and observe the community health and safety measures provided in the SS-ESMP to prevent and address risks and impacts associated with the work and labor/worker influx on the health staff, patients, visitors to the hospital and surrounding local communities. • Ensure that workers understand and sign Codes of Conduct. 10 Storage of • Provide hard compacted, impervious and No health hazard and bounded flooring to hazardous material storage water contamination hazardous occurred. areas; Label each container indicating what is material stored within; Train staff in safe handling (including techniques. infectious and toxic wastes) 11 Construction • Ensure that no contaminated effluent is No oil spill observed activities; released in to the environment. • Ensure that fuels, oils, and other hazardous substances handled and stored according to 132 # Activities Mitigation measures Monitoring causing indicators impacts handling of standard safety practices such as secondary fuels, oil spell containment. They shall be stored in the and lubricants storage where there is concrete floor and roofing • Fuel tanks should be labeled and stored in impervious lining and dykes etc. • Ensure that vehicle refueling to be planned on need basis to minimize travel and chance spills. • Ensure that operating vehicles are checked regularly for any fuel, oil, or battery fluid leakage. 12 Cutting of trees • To minimise the needs for cutting. No complaints from in the • To get agreement of the local community and local authority and/or construction community residents. area where required 13 Excavation of • Proper compaction and water sprinkling Erosion and dust channels emission minimized 14 Disposal of • Stockpile the excavated material to non- Minimum loss of excavated agriculture and in a minimum area and away habitat material from storm water 15 Loss of fertile • Remove surface soil of the location, stocked in River banks soil and a proper place and once the construction is stabilized and re- vegetation; finished, put the soil back on that place. The vegetated impacts on left-over spoil soil should be collected and kept natural aside for rehabilitation of the site at later stage vegetation and of the work; re-vegetate the embankments with embankment indigenous plant species erosion along the watercourse. 16 Dust and smoke • All truckloads of loose materials is covered Dust and smoke emissions during transportation. Water spraying or any controlled other methods are used by the Contractor to maintain the works areas, adjacent areas, and roads, in a dustless condition, as well the vehicle speed not to be exceeded from 30Km/h. Vehicles will be tuned regularly to minimize the smoke emissions. 17 Noise pollution • Vehicles and equipment used to be fitted, as Excessive noise applicable, and with properly maintained generation controlled silencers. Restriction on loudly playing radio/tape recorders etc. 133 # Activities Mitigation measures Monitoring causing indicators impacts 18 Excavation of • Excavate borrow soil up to maximum depth Borrow area borrow areas of 0.5m; with slope boundaries rehabilitated as per specification 19 Rehabilitation • Proper rehabilitation of borrow pits; Removal Borrow areas of borrow pits and storage of top 15 cm top soil having rehabilitated organic materials and spreading it back during restoration of borrow area 20 Encountering • The subproject field supervisor (CSC or filed The report from the archaeological engineer) will halt the work at the site and CSC or field sites during inform to the regional team leader and supervisor, earth works Archaeological Department immediately. community, and contractor 21 Aesthetic/ • Carry out complete restoration of the Cleanliness and scenic quality construction sites. tidiness of works sites • Remove all waste, debris, unused construction and work camp material, and spoil from the worksites. 134 Annex 6. Risks, Impacts, and Proposed Mitigation Measures during Operational Phase 1. This annex presents the potential risks and impacts that may arise during the operations of the proposed HCF in Sekong Provincial Hospital and the proposed measures to avoid/ minimize/mitigate such risks/impacts. The HCF owner is responsible for ensuring safe and effective operations of the proposed HCF. 2. According to the risk screening conducted for the HCF (see Annex 3 of the SS-ESMP), risks related to operations of the proposed HCF is considered “substantial” due to limited capacity and budget of the HCF owner and MOH technical departments as well as complexity of COVID-19 treatment facilities and wastes management. Since July 2021, the Project Coordination Office (PCO) of Department of Planning and Cooperation (DPC) in close consultation with the HCF owner and other MOH technical departments (DHR, DHHP, NCLE, etc.) has facilitated technical discussion between the WB team and MOH team 15 on the risks and mitigation measures to be conducted during detailed design and operations of the proposed HCF (see below). 3. According to the WB template provided in the Project ESMF 16 , 21 risks related to COVID-19 treatment and vaccination have been identified during operations of HCF/laboratory and all these risks are considered relevant for operations of the proposed HCF. Table A6.1 identifies the proposed measures to mitigate these risks taking into account MOH existing regulations as well as the mitigation measures recommended in the Project ESMF. These measures however are being considered/discussed among PCO, DHR, DHHP, HCF owner, and other related agencies. 4. Given limited capacity and budget on operations and maintenance (O&M) of the HCF owner and MOH technical departments to manage medical wastes on-site and off-site, it is necessary to ensure that implementation of the proposed mitigation measures (in Table A6.1) are practical in light of the urgency and risks related to COVID-19 pandemic. Scope of the technical assistance (TA) to be implemented under Component 4 of the Project (see budget in Box A6.1) are being discussed between and among WB team and MOH team taking into account priority and scope of additional supports to ensure safe and effective operations of the proposed HCF. 5. It is noted that there are MOH regulations related to infection prevention and control (IPC) and healthcare waste management (HCWM) from HCF established in 2017-2019 as well as some standard operational procedures (SOPs) established by HCF and DHHP. However, these regulations and SOPs have not incorporated specific needs for COVID-19. Nonetheless, DHHP and other MOH technical departments have also been working closely with technical 15 MOH team includes the detailed design consultant (PiSECCON), the Department of Healthcare and Rehabilitation (DHR), the Department of Environmental Hygiene and Health Promotion (DHHP), the National Center on Laboratory and Epidemiology (NCLE), WHO, Nam Saad and Department of Urban Planning (DHUP) of Ministry of Public Works and Transport (MPWT), and BORDA (BORDA is an international NGO that is providing technical support to MPWT on the design and operations of small wastewater treatment system in Lao PDR) 16 See Annex III Table A37 for operations of HCF/laboratory. 135 assistance and funding support from other international development partners (WHO, UNICEF, ADB, etc.). 6. Discussion among PCO, DHR, DHHP, and WB team are on-going taking into account the possibility to coordinate and cooperate with the ongoing WHO program related to water supply, sanitation, and health (WASH) program in Lao PDR. As of end September 2021, below summarized key agreements that have been reached between WB and MOH teams. (a) Need for appropriate design. 7. As part of detailed design, measure to mitigate the potential risks related to the layout of the facilities; heater, ventilation, and air circulation (HVAC); solid waste management; and wastewater treatment system (WWTS); and other related mechanical, water supply, and electrical systems, etc. The solid and medical wastes will be managed through the 3-bins system established per DHHP guidelines including provision of a waste storage area while a series of septic tanks and filtering system including chlorination and small retention pond will be used (see Annex 2 of the ESMP). The design has also taken into account the needs for waste sterilization (an autoclave) and chlorination of wastewater before percolation into the ground. The final design has been endorsed by WB team. 8. Next actions. Scope of the TA to be provided (under Activity 4.1.2.1) will ensure safe and effective operations of these systems as well as recommendations on ways to build capacity of MOH on WASH and medical waste management to meet short- term and medium-term needs. (b) Need for effective implementation of regulations, SOPs, and trainings. 9. Due to the urgent need to put in place the operations of the proposed HCF, it has been agreed that existing MOH regulations and SOPs will be applied during operations of the proposed HCF. However, these regulations and SOPs will be updated taking into account the new knowledge, the Government constraints, and the implementation experience during COVID-19 response in Lao PDR. Basic trainings are being provided through key MOH technical departments however, additional training will be necessary. 10. To ensure safe and effective operations of waste management from the proposed HCF, in addition to putting in place and effective implementation of the SOPs, provision of one autoclave for waste sterilization, PPEs, and other consumable materials (bins, safety-boxes, cleaning/disinfection chemicals, etc.) for staff and workers responsible for cleaning, water supply and sanitation, and waste management will be necessary. Training of staff and workers for all safety and waste management aspects of the proposed HCF will also be required. These autoclave, PPEs, consumable materials will be available before the proposed HCF construction is completed which is expected to be around May 2022. 11. Next actions. PCO and the technical departments will ensure that budget for procurement of the autoclave, PPEs, and other additional training and operational costs of the proposed HCF will be adequate at least to the end of the Project closing date (December 2023). Details will be discussed between and within WB and MOH teams. If needed and possible, these additional costs can be part of the TA to be implement under Component 4 (Activity 4.1.2.1). (c) Next Steps 136 12. In line with the mitigation measures identified in Table A6.1, follow-up discussion will also be necessary to ensure that additional TA and Project budget will be provided for effective and timely implementation of other measures identified in the SS-ESMP for operations. Of the proposed HCF including, but not limited to, the following measures: (i) Preparation of an Emergency Preparedness and Response Plan (EPRP) for addressing risks related to community health and safety (CHS), major floods and other emergency events such as fire, floods, natural disasters, etc.; (ii) Strengthening communication and stakeholder engagement to enhance knowledge and awareness (and avoiding misunderstanding and social stigma) among the HCF’s patients/visitors and concerned local authorities and communities regarding COVID- 19 contagion and infection prevention and control (IPC) including healthcare waste management (HCWM); (iii) Strengthening capacity of HCF on Wash facilities and medical waste management including setting up monitoring and reporting on waste stream on-site and off-site, updating existing MOH regulations and SOPs, and providing clarity on roles and responsibility of key agencies to ensure effective operations of the proposed HCF; (iv) Agreement on scope of the TA to be implemented under Component 4 especially those related to the implementation of the SS-ESMP for operations; and (v) Ensuring that additional budget is available for procurement of one waste sterilization autoclave, PPEs and consumable materials for waste management, cost for chlorination pellet, TA on O&M and training, etc. to ensure effective implementation of the SS-ESMP during operations of the proposed HCF. 13. After the agreements on (a) to (c) above have been reached, the proposed mitigation measures described in Table A6.1 will be updated, as needed. PCO will inform WB of any changes that may be necessary in relation to the proposed measures and plans including scope of the TA to be implemented under Component 4. It is expected that the final agreement on budget allocation will be reached by end of December 2021. 14. Attachment 1 of this Annex 6 provides generic technical guidance on the risks and mitigation measures related to COVID-19 during operations of HCF/laboratory (Table A6.2) as well as those related to procurement of goods (Table A6.3) and technical assistance and capacity building (Table A6.4) that are provided in the Project ESMF while those guidelines related to the Infection Prevention and Control (IPC) procedures and Healthcare Waste Management (HCWM) procedures are provided in Attachment 2. The HCF owner, PCO, and other MOH technical agencies have been applying these guidelines during the discussion and finalization of the proposed mitigation measures identified in Table A6.1 taking into account WHO’s recommendations (Attachment 3 of this Annex 6) and the technical options on waste management (see Box A6.3). 15. To facilitate quick and effective discussion among MOH agencies and between MOH team and WB team, scope of the proposed HCF is briefly provided in Box A6.2 while the flowchart below shows the waste management process for the proposed HCF. It is noted that in Lao PDR, especially at the existing HCF, there is a lack of reliable data on specific type of wastes management (infectious waste, pathological waste, sharps, liquid and non-hazardous and how they are managed). Given the infectious nature of the novel corona virus, some wastes 137 that are traditionally classified as non-hazardous may be considered hazardous. It’s likely that the volume of waste will increase considerably given the number of admitted patients during COVID-19 outbreak. Special attention should be given to the identification, classification and quantification of the healthcare wastes. Attachment 3 of this Annex 6 provide key recommendations of WHO (WASH program) in Lao PDR and they are also being considered during the on-going discussion process. Box A6.1 Component 4 budget in USD (as of October 2021) HEPR Trust Project component and main activities Fund COMPONENT 4: Strengthening Preparedness for Health Emergency Respond 2,000,000 4.1 Enhancing health systems and facilities for future emergencies 1,700,000 Assessment of health facilities preparedness (including the WASH services and medical 4.1.1 130,000 waste management in health care facilities) for health emergencies 4.1.2 Establishment of health facilities with enhanced emergency preparedness 1,500,000 TA on medical waste mangement, including sharp wastes, wastewater and quality of 4.1.2.1 900,000 isolation treatment center management 4.1.2.2 Minor civil work for improvement of quality of the isolation, treatment facilities 600,000 Review of roles, responsibilities, and standard operating procedures in emergency 4.1.3 70,000 management operations Preparing for health emergencies by developing and implementing preparedness 4.2 240,000 assessments and plans, conducting simulation exercises 4.2.1 Identification of critical lifeline infrastructure that are vulnerable to disasters 70,000 4.2.2 Assessment of healthcare supply chain vulnerabilities 100,000 Development of multi-hazard business continuity plans for health facilities, lifeline 4.2.3 70,000 infrastructure and basic services 4.3 Estimating resource needs in case of a health emergency 60,000 4.3.1 Estimate water and sanitation resources needed in case of a health emergency 60,000 Box A6.2 Scope of the proposed HCF in Sekong Provincial Hospital, Sekong Province (a) Description and existing HCW management • The new HCF for treatment of COVID-19 will be constructed within the premise of the Sekong Provincial Hospital. The new HCF will be built within the existing SPH premise and comprise of three new one-story buildings with an estimated area of 1,529m2.To make way for the new HCF, eight existing buildings of the SPH will be demolished. Four new buildings will be constructed, including Building No 1 (ICU, 6 beds), Building No 2 (Isolation Ward, 16 beds), Building No 3 (Laboratory), 138 and Building No. 4 (Waste Management). Building No 1 will be connected to an existing old building a roofed walkway. The old building has an isolation capacity of 8 beds. The total number of beds (from new and old buildings) will be 30. • Given the risks related to COVID-19, design of the proposed HCF was extensively discussed and the final design is provided in Annex 2. Key agreements are related to the general layout and specification including heating, ventilation, and air conditioning (HVAC), access to water and power supplies, and solid/liquid waste management had been discussed and agreed with the WB. It has been agreed that the infection waste will be treated with an autoclave before final disposal at the provincial landfill. Sewage and wastewater treatment for the buildings will be made through a series of fabricated oil/grease trapping, septic tank, filtration tanks, and a small pond while chlorination will be made before the effluent is discharged to a pond to be naturally treated then flow out to public drain. Box A6.3 Technical options on waste management measures • Waste minimization, reuse and recycling: HCF should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety considerations. • Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies: HCF should adopt practice and procedures to minimize risks associated with delivering, receiving and storage of hazardous medical goods. • Waste segregation, packaging, color coding and labeling: HCF should strictly conduct waste segregation at the point of generation. Internationally adopted method for packaging, color coding and labeling the wastes should be followed. • Onsite collection and transport: HCF should adopt practices and procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes. Disinfection of pertaining tools and spaces should be routinely conducted. Hygiene and safety of involved supporting medical workers such as cleaners should be ensured. • Waste storage: A HCF should have multiple waste storage areas designed for different types of wastes. Their functions and sizes are determined at design stage. Proper maintenance and disinfection of the storage areas should be carried out. Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF’s storage area for disposal within 24 hours. The HCF will follow the HCWM procedure and guideline for implementing such work. • Onsite waste treatment and disposal (e.g. an incinerator): Many HCFs have their own waste incineration facilities installed onsite. Due diligence of an existing incinerator should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended. For new HCF financed by the project, waste disposal facilities should be integrated into the overall design and ESIA developed. Good design, operational practices and internationally adopted emission standards for healthcare waste incinerators can be found in pertaining EHS Guidelines and GIIP. • Transportation and disposal at offsite waste management facilities: Not all HCF has adequate or well- performed incinerator onsite. Not all healthcare wastes are suitable for incineration. An onsite incinerator produces residuals after incineration. Hence offsite waste disposal facilities provided by local government or the private sector are probably needed. These offsite waste management facilities may include incinerators, hazardous wastes landfill. In the same vein, due diligence of such external waste management facilities should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended and agreed with the government or the private sector operators. Then the government or relevant stakeholders such as PHO, DHO and Urban Development Agency will find solution to improve proper waste management and disposal and/or to improve the standardized sanitation landfill for the long run. • Wastewater treatment: HCF wastewater is related to hazardous waste management practices. Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream. In case wastewater is discharged into municipal sewer sewerage system, the HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the municipal wastewater treatment plant (WWTP) is capable of handling the type of 139 effluent discharged. In cases where municipal sewage system is not in place, HCF should build and properly operate onsite primary and secondary wastewater treatment works, including disinfection. Residuals of the onsite wastewater treatment works, such as sludge, should be properly disposed of as well. There’re also cases where HCF wastewater is transported by trucks to a municipal wastewater treatment plant for treatment. Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance should be conducted. 140 Table A6.1 – Proposed Mitigation Measures during Operational Phase of the Proposed HCF (O-ESMP) (Per the template provided in Project ESMF Annex III Table A3.7; Italic letter reflects reference information) Potential ES Risks/Impacts Proposed Mitigation Measures (* means on-going discussion or to be discussed) Responsibilities Timeline/ Budget (number, #) (1) General HCF operations – Environment • General wastes, wastewater, and air On solid waste: PCO, DHR, • During emissions. DHHP, PHO/ operations. • Use of on-site incinerator or burning of solid wastes onsite are prohibited. DHO, and HCF • It is noted that in Lao PDR, especially • Improve capacity of HCF owner to ensure safety and effective management of owners • Budget to at the existing HCF, there is a lack of solid and medical wastes using the 3-bins system, safety box, waste storage area, be reliable data on specific type of waste sterilization using autoclave as well as provision of one autoclave for waste allocated wastes management (infectious waste, sterilization, PPEs, consumable materials and chemicals, and training to HCF staff under pathological waste, sharps, liquid and and workers responsible for cleaning and waste management. appropriate non-hazardous and how they are • Put in place specific agreement (and cost for the services) between the HCF owner Project managed). and the waste collectors for off-site disposal. Staff of the service provider will component have to be trained while appropriate PPEs will be provided by the service provider. • Put in place a plan to hire qualified operators of the autoclave and assign the focal point of the HCF owner to be responsible for ensuring safe and effective management of waste to be generated from the proposed HCF. This will also include training and budget to be provided at least to the end of the Project closing date. • The TA to be implemented under Component 4 will provide support for the preparation of an action plan and its implementation to ensure effective SOP, waste management, O&M, and training for general and medical waste during operations of the proposed HCF. Box below will be considered, as appropriate, during the implementation of the TA. Box. ESMF recommendations a) Estimate potential waste streams, including sharps and vaccine program wastes 141 b) Consider the capacity of existing facilities, and plan to increase capacity, if necessary, through construction, expansion etc. c) Specify that the design of the facility considers the collection, segregation, transport and treatment of the anticipated volumes and types of healthcare wastes d) Require that receptacles for waste should be sized appropriately for the waste volumes generated, and color coded and labeled according to the types of waste to be deposited. e) Develop appropriate protocols for the collection of waste and transportation to storage/disposal areas in accordance with WHO guidance. Design training for staff in the segregation of wastes at the time of use. On wastewater • Measures have been considered and included in the detailed design. • To address wastewater issues, a fabricated septic tank system (with aeration) has been included in the detailed design and installation will be completed when construction of the proposed HCF is completed (expected in mid-2022). The wastewater from the septic tank will go through a series of 2 retention tanks while the wastewater quality will be tested to meet the national environmental standards before going through the chlorination, filtering, and percolation process. A small retention pond will also be provided to address possible overflow issue during wet season. • The TA to be implemented under Component 4 will provide support to ensure effective O&M of the proposed WWTS at least to the end of the December 2023 (Project closing date), including provide training to the HCF staff. On air emission • Measures have been considered and included in the detailed design. • To address air emission issues, HVAC and building layout have been designed taking into account the need to address issues related to air circulation and possible contamination within the facilities. (2) General HCF operations– OHS issues • Physical hazards; Electrical and • Apply existing GOL and MOH regulations and provide adequate PPEs and training Same as (1) Same as (1) explosive hazards; Fire; Chemical to staff and workers. above above 142 use; Ergonomic hazard; Radioactive • Establish a SOP on OHS including posting visible hazardous warning signs and hazard. labelling as much as possible. • Provide knowledge on OHS for staff and workers responsible for operations of the proposed HCF especially those related to electrical and mechanism systems including chlorination, hazardous wastes, and toxic chemicals and other related knowledge regarding COVID-19 contagion and other hazards. • Prepare an Emergency Preparedness and Response Plan [see EPRP in Risk # (6) below]. • *If possible, the TA to be implemented under Component 4 will provide support for the preparation and implementation of a plan for training, putting the SOP on OHS in place, and preparation of the EPRP. (3) HCF operations – Labor issues • Lack of clear information and • Apply Box below as appropriate including segregation of information by gender and Same as (1) Same as (1) planning on work forces and clear vulnerable ethnic groups. above above procedure for ensuring compliance • Identify the need for using security personnel during operations. If this is needed, with GOL regulations (2013 Labor inform PCO. law). • Ensure clarity on procedures to comply with GOL regulations related to the labor and other related laws and regulations. • The Project ESMF identified 6 key • Consider signing the social code of conduct (SCOC) for staff and workers support by risks related to workers and staff of the Project. Consultation with PCO will be required. the proposed HCF during operations • Apply appropriate mitigation measures provided for these risks as identified in the of HCF/laboratory in light of COVID- Item (5), (6), (7), (8), (9) and (10) in Table A6.2 of Attachment 1 of this Annex 6]. 19 pandemic and related treatment [see Item (5), (6), (7), (8), (9) and • *If possible, the TA to be implemented under Component 4 will provide support for (10) in Table A6.2 of Attachment 1] the preparation and implementation of an action plan on the labor/worker management of the proposed HCF. Box. ESMF recommendations ➢ Identify numbers and types of workers ➢ Consider accommodation and measures to minimize cross infection ➢ Use the COVID-19 LMP template to identify possible mitigation measures (4) HCF operations - considerations for differentiated treatment for groups with different needs (e.g. the elderly, those with preexisting conditions, the very young, people with disabilities) 143 • The Project ESMF identified 5 key • Identify the needs for an effective communication campaign on the HCF services risks related to different needs of including tailored outreach to different groups (including disadvantaged and different groups of people during vulnerable groups), with different partners. operations of HCF/laboratory in light • Apply appropriate mitigation measures provided for these risks as identified in Item of COVID-19 pandemic and related (11), (12), (13), (14), and (15) in Table A6.2 of Attachment 1 of this Annex 6 . treatment [see Item (11), (12), (13), (14), and (15) in Table A6.2 of • *If possible, the TA to be implemented under Component 4 will provide support for Attachment 1 of this Annex 6] the preparation and implementation of an effective communication campaign/plan for the proposed HCF, which aiming to provide treatment for the COVID-19. The plan will also address the risks and social issues identified in the risks #19, 20, and 21 below. (5) HCF operations – cleaning • Risks on COVID-19 infection if not • Apply Box below as appropriate. Same as (1) Same as (1) properly training and/or use • Putting in place a SOP for cleaning for COVID-19 patients taking into account the above above appropriate PPEs (especially when procedures provided in Attachment 2 (IPCP and HCWMP) of the Annex 6. use disinfection chemicals and etc.) • Provide training and post specific procedures and/or warning signs, as needed. and/or do not dispose of infection/ toxic waste correctly. • *If possible, the TA to be implemented under Component 4 will provide support for the preparation and implementation of an action plan on cleaning and handling of toxic chemicals and hazardous waste for staff and workers of the proposed HCF. Box ESMF recommendations ➢ Provide cleaning staff with adequate cleaning equipment, materials and disinfectant. ➢ Review general cleaning systems, training cleaning staff on appropriate cleaning procedures and appropriate frequency in high use or high-risk areas. ➢ Where cleaners will be required to clean areas that have been or are suspected to have been contaminated with COVID-19, provide appropriate PPE: gowns or aprons, gloves, eye protection (masks, goggles or face screens) and boots or closed work shoes. If appropriate PPE is not available, provide best available alternatives. ➢ Train cleaners in proper hygiene (including handwashing) prior to, during and after conducting cleaning activities; how to safely use PPE (where required); in waste control (including for used PPE and cleaning materials). ➢ 144 (6) HCF operation - Infection control and waste management plan (ICWMP) –see brief scope of the proposed HCF in Box A6.2 of this Annex 6 • As identified in the Project ESMF, • These emergency events are likely to seriously affect medical workers, communities, Same as (1) Same as (1) scope of the ICWMP should include the HCF’s operation and the environment. Thus, an Emergency Preparedness and above above brief description of the project, Response Plan (EPRP) that is risk based will be developed. The key elements of the Emergency Preparedness and EPRP are defined in ESS 4 Community Health and Safety (para. 21 of the WB’s Response Plan (EPRP), institutional ESF). arrangement and capacity building, • Apply Box below as appropriate. and monitoring and reporting. • Prepare SOP for the HCF in line with the guidelines provided in the Project ESMF Annex IV for IPC procedures and HCWM procedures taking into account the • The ESMF also identified a risk related application of recent MOH regulations and technical guidelines. to weak compliance with the precaution measures for infection • *If possible, the TA to be implemented under Component 4 will provide support for prevention and control in isolation and the preparation and implementation of an action plan on ICWMP for the proposed treatment of infected cases spreads HCF, including those related to EPRP, implementation of regulation, and COVID-19 infections in healthcare monitoring/reporting as recommended in the ICWMP template provided below. facilities [see risk (2) in Table A6.2 in Attachment 1 of this Annex 6]. Box ESMF Recommendations ➢ Special considerations need to be made to vulnerable groups in delivering these • Emergency incidents occurring in a services. HCF may include spillage, ➢ Health facilities should establish and apply Standard Precautions including: Hand occupational exposure to infectious Hygiene (HH); Respiratory hygiene/cough etiquette; Use of personal protective materials or radiation, accidental releases of infectious or hazardous equipment (PPE); Handling of patient care equipment, and soiled linen; substances to the environment, failure Environmental cleaning; Prevention of needle-stick/sharp injuries; and Appropriate of medical equipment and solid waste Health Care Waste Management (See Annex V: Standard Precautions). and wastewater treatment facilities, ➢ In addition, health facilities should establish and apply transmission based fire, and other natural disasters. precautions (contact, droplet, and airborne precautions) as well as specific procedures for managing patients in isolation room/unit (See Annex V: transmission- based precautions and specific measures for managing patients in isolation room/unit). • Clarity on legal and institutional • Apply Box below as appropriate. Same as (1) Same as (1) arrangement, roles and responsibilities, above above and training of key staff and workers are critical and a training plan with 145 recurring training programs should be • *If possible, the TA to be implemented under Component 4 will provide support for developed. the preparation and implementation of an action plan to ensure effective • Review of legal and institutional implementation of MOH regulations (as part of the ICWMP). arrangement suggested that most of the Box ICWMP Recommendations on institutional arrangement and capacity building. technical managers know what need to be done to ensure effective and safe operations of HCF. However, limited • Define roles and responsibilities along each link of the chain along the cradle-to- budget operational budget and limited crave infection control and waste management process; number and knowledge of professional • Ensure adequate and qualified staff are in place, including those in charge of staff and workers need to be infection control and biosafety and waste management facility operation. strengthened. • Stress the chief of a HCF takes overall responsibility for infection control and waste management; • Involve all relevant departments in a HCF, and build an intra-departmental team to manage, coordinate and regularly review issues and performance; • Establish an information management system to track and record the waste streams in HCF; and • Capacity building and training should involve medical workers, waste management workers and cleaners. Third-party waste management service providers should be provided with relevant training as well. Monitoring and Reporting • Apply Box below as appropriate. Same as (1) Same as (1) above above • As mentioned in the Project ESMF • *If possible, the TA to be implemented under Component 4 will provide support for Annex V, many HCFs in developing the preparation and implementation of an action plan on monitoring and reporting countries face the challenge of (as part of ICWMP). inadequate monitoring and records of healthcare waste streams. Box ICWMP Recommendations • The HCF chief takes overall • The HCF should establish an information management system (IMS) to track and responsibility, leads an intra- record the waste streams from the point of generation, segregation, packaging, departmental team and regularly temporary storage, transport carts/vehicles, to treatment facilities. reviews issues and performance of the • The HCF is encouraged to develop an IT based information management system infection control and waste should their technical and financial capacity allow. management practices in the HCF. • Internal reporting and filing systems should be in place. Externally, reporting should be conducted per government and World Bank requirements. 146 (7) Mass vaccination program involving deployment of vaccines from many facilities (not just HCF), vehicles and locations • Mass vaccination provides a vector • It is expected that the proposed HCF will also provide services on COVID-19 Same as (1) Same as (1) for the spread of disease. vaccination. above above • During operations of HCF/ laboratory • Follow the procedures related to cold chain management and transportation and those provided services on COVID-19 related to AEFI as described in the national deployment of vaccines program (NDVP) treatment, the Project ESMF and/or as required by the ESMP on vaccines program to be endorsed by WB. identified 2 key risks related to • Apply appropriate mitigation measures provided for these risks as identified in the effectiveness of vaccines cold chain risks # (13) and (14) of Table A6.2 in Attachment 1 of this Annex 6. temperature monitoring [item (13) of Table A6.2 in Attachment 1 of this • *If possible, the TA to be implemented under Component 4 will provide support for Annex 6] and capacity assessment of the implementation of the ESMP on vaccination program including those related to the proposed HCF and/or MOH to monitoring and reporting, procurement, transportation, storage and cold chain monitor adverse events following management [see the risk # (9) and (10) below], etc. (the ESMP for vaccination immunization (AEFI) in line with program is being prepared separately). WHO guidelines. • Insufficient capacity for ensuring immunization safety through detecting, reporting, investigating and responding to AEFI. • Failure to store and handle vaccines properly can reduce vaccine potency, resulting in inadequate immune responses in patients and poor protection against disease [Item (14) of Table A6.2 in Attachment 1 of this Annex 6]. (8) Waste minimization, reuse and recycling • Use of incinerators results in emission • Use of low incinerator and open burning is prohibited for the proposed HCF (see Same as (1) Same as (1) of dioxins, furans and particulate Risk # (1) above). matter • *If possible, the TA to be implemented under Component 4 may also consider an option to establish a regional incinerator for the southern province if needed. Box below as well as those guidances provided in the ICWMP (see Box A6.3) and those 147 provided in Attachment 2 and Attachment 3 of this Annex 6 should be considered as appropriate during the preparation of the TA’s TOR. Box ESMF recommendations ➢ Where possible avoid the use of incinerators ➢ If small-scale incineration is the only option, this should be done using best practices, and plans should be in place to transition to alternative treatment as soon as practicable (such as steam treatment prior to disposal with sterile/non-infectious shredded waste and disposed of in suitable waste facilities) ➢ Do not use single-chamber, drum and brick incinerators. ➢ If small-scale incinerators are used, adopt best practices to minimize operational impacts. (9) Procurement, delivery and set up of equipment for the storage and handling of vaccines and associated medical equipment • Appy Box below as appropriate. • Surfaces of imported materials may Same as (1) Same as (1) be contaminated and handling and • Apply the relevant mitigation measures identified in Table A6.3 in the Attachment 1 above above processing may result in spread of of this Annex 6 taking into account the GOL policy and regulations. COVID-19. • *If possible, the TA to be implemented under Component 4 will provide support for • The ESMF identified detailed risks the implementation of the ESMP on vaccination program (see Risk # (7) above). related to procurement of goods during COVID-19 pandemic in Table Box ESMF recommendations A6.2 of Attachment 1 of this Annex 6. ➢ Technical specifications for procuring equipment should require good hygiene practices in line with WHO technical guidance to be observed when preparing the procured goods. ➢ Check national and WHO technical guidance for latest information regarding transmission of COVID on packaging prior to finalization of working protocols at facilities receiving procured goods and update working methods as necessary. (10) Transport of goods or supplies, including the delivery, storage and handling of vaccine, specimen, samples, reagents, pharmaceuticals and medical supplies • COVID-19 is spread by drivers • Apply Box below as appropriate. Same as (1) Same as (1) during the transport and distribution above above • Provide knowledge and training to the drivers and monitor their performance. of goods or supplies. 148 • Traffic accidents may occur during • *If possible, the TA to be implemented under Component 4 will provide support for transportation of goods. the implementation of the ESMP on vaccination program (see risk # (7) above). *Note. Also see issues in (15 below) Box ESMF recommendations ➢ Good hygiene and cleaning protocols should be applied. During the transport, truck drivers should be required to wash hands frequently and /or be provided with hand sanitizer, and taught how to use it. ➢ Measures to minimize impacts during transportation, including hazardous materials can be found in the EHSGs (environment, health, and safety guidelines of the WB group). (11) Onsite solid waste segregation, packaging, color coding and labeling, and storage • Increase safety and infection risks due • Provide a waste storage area for medical wastes. This has been included in the Same as (1) Same as (1) to lack of understanding, awareness, above above detailed design of the proposed HCF. Details guidance on the design and and cooperation of HCF staffs, management is also provided by WHO (see Attachment 3 of this Annex 6). workers, patients and visits do not follow instruction on properly • Put in place SOP on solid waste segregation, packing, color coding and labelling separate solid waste from other taking into account MOH regulations as well as the guideline provided in the Project medical wastes ESMF Annex IV, especially those related to infection prevention and control procedure (IPCP) and the healthcare waste management procedures (HCWMP) (see Attachment 2 of this Annex 6). • Put in place communication materials and appropriate bins, bags, etc. The HCF owner will assign the focal point to be responsible for ensuring effective management of solid waste management on-site. • Provide training to all staff and workers responsible for these aspects on-site and ensure that workers from the waste collector suppliers also have knowledge and follow strictly procedures to collect waste and dispose of off-site according to the agreement. • *If possible, the TA to be implemented under Component 4 may also provide support for the development of SOP on these aspects including provide budget for PPE, chemical and consumable supplies, and training of staff and workers (also see Risk # (1) above). (12) Onsite waste collection and transport 149 • Safety and infection risks due to lack • Specific requirement will be part of the waste collection services between the HCF Same as (1) Same as (1) of understanding, awareness, and above above owners and a local service provider. cooperation of HCF staffs, workers, patients and visits do not follow • The HCF focal point will also ensure that onsite waste collection, transport, and instruction on properly separate solid storage are properly and safely managed. He/she will have adequate knowledge and waste from other medical wastes be trained for the whole management cycle of hospital waste management and risks. • Off-site disposal of solid wastes from hospital outside the designated area and open burning will not be allowed. • *If possible, the TA to be implemented under Component 4 may also provide support for the development of a SOP to be included as part of the contract between HCF owner and the service provider (see also Risk # (1) above). (13) Onsite medical waste (infection, sharp) treatment and disposal • Inappropriate treatment and disposal • Provision of one autoclave will be procured for waste sterilization at the HCF and it Same as (1) Same as (1) of infection and shar waste will create will be operations before the construction is completed (mid 2022). One operator will safety risk and may spread infection also be hired to ensure effective and safe operations of the machine (including to HCF professional, staff, and checking for good water and electricity supply during operations and proper workers. maintenance). • *If possible, the TA to be implemented under Component 4 may also provide support for the development of a SOP to handle infection and sharp waste while adequate budget will be provided to ensure availability of safety boxes, disinfection chemicals, and appropriate PPEs (see also Risk # (1) above). (14) Transportation and disposal at offsite waste management facilities • Increase safety and infection risks to • The HCF focal point will also ensure that the waste collector who provide the Same as (1) Same as (1) the public due to inappropriate service strictly follow the offsite disposal. The worker must be trained and follow transportation and disposal of hospital the instruction and agreement. waste offsite by the HCF workers and/or the waste collection provider. • Off-site disposal of solid wastes from hospital outside the designated area and open burning will not be allowed. • Ensure adequate budget for the waste collection services is available. 150 • *If possible, the TA to be implemented under Component 4 may also provide support for the development of a SOP to be included as part of the contract between HCF owner and the service provider (part of ICWMP). (15) HCF operations – transboundary movement of vaccine, specimen, samples, reagents, medical equipment, and infectious or hazardous materials • The Project ESMF identified 1 key • The national (NDVP) has been developed and an ESMP for the COVID-19 program Same as (1) Same as (1) risk related to improper collection of will also be established. Vaccination of COVID-19 will be made according to the samples and testing for COVID19, as NDVP as well as the ESMP approved by WB and GOL. well as improper transport/ storage/handling and delivery of the • Apply appropriate mitigation measures provided for these risks (item (1), (2), (3), and COVID vaccine and appropriate (4) as identified in the Table A6.2 of Attachment 1 of this Annex 6. laboratory biosafety and/or infectious • The SOP to be developed taking into account the GOL policies and regulations waste could result in spread of disease related to COVID-19 pandemic and the mitigation measures provided in Table A6.2 to medical workers or laboratory (Attachment 1 of this Annex 6) and discussion/agreement among PCO, DHR, DHHP, workers, other non-medical staff, PHO, DHO, and HCF owners. patients or population during the transport of potentially affected • Provide appropriate knowledge, SOP, PPE, and training to HCF staff (including samples. those in the laboratory). • There are also risks related to noncompliance with MOH • *If possible, the TA to be implemented under Component 4 will provide support for regulations, inadequate availability of the preparation and implementation of an action plan to address these risks (as part chemical, and/or treatment and of the ICWMP) and as well as addressing the risk related to transportation and cold management of toxic and hazardous wastes and chemicals during chain for the proposed HCF (as part of the implementation of the ESMP for operations of HCF/laboratory in light vaccination program). of COVID-19 pandemic and related treatment [see Item (1), (2), (3, and (4) in Table A6.2 of Attachment 1 of this Annex 6] (16) Operations of acquired assets for holding potential COVID-19 patients • Not applicable. (17) Emergency events 151 • Spillage; Occupational exposure to • Apply Box below as appropriate. Same as (1) Same as (1) infectious disease; Exposure to • Apply the measures identified to mitigate these risks in # (2) (EPRP) and # (6) above above above radiation; Accidental releases of (ICWMP). infectious or hazardous substances to the environment; Medical equipment • *If possible, the TA to be implemented under Component 4 will provide support on failure; Failure of solid waste and the preparation of the EPRP (also see Risk # (2) above). wastewater treatment facilities; Fire; and Other emergent events Box ESMF recommendations Prepare an Emergency Preparedness Response Plan (EPRP) [see issue (6) above] (18) Mortuary arrangements • Arrangements and capacity are • Apply Box below as appropriate during planning and implementation of the proposed Same as (1) Same as (1) insufficient HCF. above above • Possible spread of infection • Develop SOP on this aspect and provide training to all staff. • *If possible, the TA to be implemented under Component 4 will provide support for the preparation of a clear plan to address these risks (as part of the ICWMP or Vaccination program) Box. ESMF recommendations ➢ Include adequate mortuary arrangements in the design –This is not included in the design yet. See WHO Infection Prevention and Control for the safe management of a dead body in the context of COVID-19) ➢ Implement good infection control practices (see WHO Infection Prevention and Control for the safe management of a dead body in the context of COVID-19). ➢ Use mortuaries and body bags, together with appropriate safeguards during funerals (see WHO Practical considerations and recommendations for religious leaders and faith- based communities in the context of COVID-19). (19) Vaccination campaign - considerations for communication and outreach for disadvantaged and vulnerable groups • Risks due to mis-communication, • Apply measure as identified in (4) above. Same as (1) Same as (1) inadequate information provided, above above social stigma, etc. 152 (20) Stakeholder engagement – considerations for simple, accurate, accessible and culturally appropriate information dissemination; combating misinformation; responding to grievances • Risks of complains due to • Apply the measures identified for addressing the risks #(4) above as appropriate. Same as (1) Same as (1) miscommunication, social stigma, and other constraints is high. (21) Targeting of beneficiaries (for vaccination) is not done in a fair, equitable and inclusive manner • Lack of transparency about the • Apply Box below as well as the measures identified for addressing the risks in #(4) Same as (1) Same as (1) vaccination program above above above as appropriate. Box ESMF recommendations ➢ Outreach/communication tools to make potential beneficiaries aware of the eligibility criteria, principles and methods used for targeting. ➢ Ensure project includes a functional Grievance Mechanism. • Poorest / most needy households are ➢ Apply Box below as well as the measures identified for addressing the risks in #(4) Same as (1) Same as (1) left out above as appropriate. above above Box ESMF recommendations ➢ See above. Clear, transparent and unambiguous eligibility criteria ➢ Use good quality Government data combined with geographical targeting. ➢ Use local community structures to identify and select beneficiaries, based on inclusive consultations • Lack of diversity and inclusion in • Apply Box below as well as the measures identified for addressing the risk # (4) Same as (1) Same as (1) vaccination program, resulting in above above above as appropriate. inadequate benefits for other vulnerable groups Box ESMF recommendations 153 ➢ Ensure women participate in the program and, where possible, give preference to women within households as transferees. ➢ Work with community representatives/ NGOs so that vulnerable groups such as unaccompanied children, youth, Sexual Exploitation and Abuse/Sexual Harassment (SEA/SH), survivors, Indigenous Peoples, Violence Against Children (VAC), LGBTI communities, refugees, internally displaced peoples etc. are included in project activities and benefits • SEA/SH/VAC increase in project area • Apply Box below as well as the measures identified for addressing the risk # (4) Same as (1) Same as (1) (e.g. requests for sexual favors to above above above as appropriate. receive vaccinations) Box ESMF recommendations ➢ Consultations to discuss process for identifying vaccination prioritization ➢ Grievance Redress Mechanism (GRM) to be established as soon as possible to handle complaints ➢ Provide information to potential beneficiaries on eligibility criteria and GRM process via various media (radio, SMS, television, online, posters). ➢ Work with local NGOs to provide social services for affected beneficiaries, as well as assistance to register. 154 Attachment 1. Risks and Mitigation Measures Related to COVID-19 as provided in the Project ESMF Note: This attachment is provided as a quick reference for the on-going discussion among PCO, DHR, DHHP, and the HCF owners. They reflect the generic guidelines on the risks and mitigation measures identified in the Project ESMF Annex III for operations of a HCF and laboratory (Table A6.2), procurement of goods (Table A6.3), and technical assistance and training (Table A6.4). Table A6.2: Risks, Impacts, and Proposed Mitigation Measures during Operational Phase (Per the generic guidelines/template provided in ESMF Annex III Table A3.3) Risks and Impacts Proposed Mitigation Measures Responsibilities ➢ Collection of samples, transport of samples and testing of the clinical specimens from patients (1) Improper collection of samples and PCO, DHR, DHHP, testing for COVID19, as well as meeting the suspect case definition should be performed in accordance with WHO interim guidance PHO/DHO, and improper transport/storage/handling Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases. Tests HCF owners and appropriate laboratory biosafety should be performed in appropriately equipped laboratories (specimen handling for molecular and/or infectious waste could result in testing requires BSL-2 or equivalent facilities) by staff trained in the relevant technical and safety spread of disease to medical workers or procedures. laboratory workers, other non-medical ➢ National guidelines on laboratory biosafety should be followed. There is still limited information on staff, patients or population during the the risk posed by COVID-19, but all procedures should be undertaken based on a risk assessment. transport of potentially affected samples. For more information related to COVID-19 risk assessment, see specific interim guidance document: WHO interim guidance for laboratory biosafety related to 2019-nCoV. Samples that are potentially infectious materials (PIM) need to be handled and stored as described in WHO document Guidance to minimize risks for facilities collecting, handling or storing materials potentially infectious for polioviruses (PIM Guidance). For general laboratory biosafety guidelines, see the WHO Laboratory Biosafety Manual, 3rd edition. ➢ Procedures for entry into health care facilities, such as minimizing visitors and visitor hours, taking temperature checks and having separate area (including entry area) for patients presenting with COVID-19 symptoms/ respiratory illness, who should be taken to a different area and given a face mask. All persons visiting hospitals should wash hands before entering and before leaving, and there should be a simple poster/signane (can be A4 paper) in Lao language explaining entry procedures. ➢ Use of Personnel Protection Equipment (PPE) at all times for medical staff and cleaners as needed (particularly facemask, gowns, gloves, eye protection and potentially face shield) when in contact with someone who may have COVID-19/ who is presenting with a respiratory illness, including for 155 those caring directly for patients, cleaners entering patient’s room, or where patient has been treated, and lab technicians handling blood samples. Train staff on how to use the PPE, especially the less educated workers (such as cleaners). Put reminders in hospitals (paper/signane) in Lao language. ➢ General cleaning strategies: (i) proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms; (ii) proceed from top areas to bottom areas to prevent dirt and microorganisms from dripping or falling down and contaminating already cleaned areas (for example clean mattress first, then clean bed legs); (iii) proceed in a methodical, systematic manner to avoid missing areas (for example, proceed from left to right or clockwise). Provide training to cleaning staff on these procedures, as well as on the use of PPE equipment, and put signage of reminders throughout health centers. ➢ Labor personnel needs to be trained and acquainted with key provisions in Labor Management Plan (LMP), in particular Occupational Health and Safety (OHS) aspects. ➢ Adequate facilities for hand washing available. If hand washing is not possible, appropriate antiseptic hand cleanser and clean cloths / antiseptic towelettes should be provided. Hands should then be washed with soap and running water as soon as practical. Reminders should be placed throughout the health care facility, including pictorial on how to properly hand wash. ➢ Hospitals/health centers will also need to develop procedures and facilities for handling dirty linen and contaminated clothing, and preparing and handling food. Dirty linen and clothing from patients with COVID-19 should be washed separately, ensuring staff doing the washing are also practicing hand washing measures and wearing needed PPE equipment (such as masks, gowns, gloves, eye protection and close shoes). Linen and clothing should be washed in hot water. ➢ Open burning and incineration of medical wastes can result in emission of dioxins, furans and particulate matter, and result in unacceptable cancer risks under medium (two hours per week) or higher usage. ➢ If small-scale incinerators are the only option available, the best practices possible should be used, to minimize operational impacts on the environment. Single-chamber, drum and brick incinerators do not meet the Best Available Techniques (BAT) requirements under Stockholm Convention. Small- scale incineration should be viewed as a transitional means of disposal for health-care waste. ➢ Alternative treatments should be designed into longer term projects, such as steam treatment methods. Steam treatment should preferably be on site, although once treated, sterile/non-infectious waste may be shredded and disposed of in suitable waste facilities. ➢ The project health facilities should establish and apply procedures for healthcare waste management in line with WHO guidelines for Safe management of wastes from health-care activities and National guidelines for Infection Prevention and Control healthcare facilities Healthcare Waste Management Guidelines 2011” and “National Injection Safety Guidelines 2014. 156 ➢ Use of Personnel Protection Equipment (PPE) at all times for medical staff and cleaners as needed (particularly facemask, gowns, gloves, eye protection and potentially face shield) when in contact with someone who may have COVID-19/ who is presenting with a respiratory illness, including for those caring directly for patients, cleaners entering patient’s room, or where patient has been treated, and lab technicians handling blood samples. Train staff on how to use the PPE, especially the less educated workers (such as cleaners). Put reminders in hospitals (paper/signane) in Lao language. ➢ General cleaning strategies: (i) proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms; (ii) proceed from top areas to bottom areas to prevent dirt and microorganisms from dripping or falling down and contaminating already cleaned areas (for example clean mattress first, then clean bed legs); (iii) proceed in a methodical, systematic manner to avoid missing areas (for example, proceed from left to right or clockwise). Provide training to cleaning staff on these procedures, as well as on the use of PPE equipment, and put signage of reminders throughout health centers. ➢ Labor personnel needs to be trained and acquainted with key provisions in Labor Management Plan (LMP), in particular Occupational Health and Safety (OHS) aspects. ➢ Adequate facilities for hand washing available. If hand washing is not possible, appropriate antiseptic hand cleanser and clean cloths / antiseptic towelettes should be provided. Hands should then be washed with soap and running water as soon as practical. Reminders should be placed throughout the health care facility, including pictorial on how to properly hand wash. ➢ Hospitals/health centers will also need to develop procedures and facilities for handling dirty linen and contaminated clothing, and preparing and handling food. Dirty linen and clothing from patients with COVID-19 should be washed separately, ensuring staff doing the washing are also practicing hand washing measures and wearing needed PPE equipment (such as masks, gowns, gloves, eye protection and close shoes). Linen and clothing should be washed in hot water. ➢ Open burning and incineration of medical wastes can result in emission of dioxins, furans and particulate matter, and result in unacceptable cancer risks under medium (two hours per week) or higher usage. ➢ If small-scale incinerators are the only option available, the best practices possible should be used, to minimize operational impacts on the environment. Single-chamber, drum and brick incinerators do not meet the Best Available Techniques (BAT) requirements under Stockholm Convention. Small- scale incineration should be viewed as a transitional means of disposal for health-care waste. 157 ➢ Alternative treatments should be designed into longer term projects, such as steam treatment methods. Steam treatment should preferably be on site, although once treated, sterile/non-infectious waste may be shredded and disposed of in suitable waste facilities. ➢ The project health facilities should establish and apply procedures for healthcare waste management in line with WHO guidelines for Safe management of wastes from health-care activities and National guidelines for Infection Prevention and Control healthcare facilities Healthcare Waste Management Guidelines 2011” and “National Injection Safety Guidelines 2014. ➢ Special considerations need to be made to vulnerable groups in delivering these services. (2) Weak compliance with the precaution Same as (1) above measures for infection prevention and ➢ Health facilities should establish and apply Standard Precautions including: Hand Hygiene (HH); control in isolation and treatment of Respiratory hygiene/cough etiquette; Use of personal protective equipment (PPE); Handling of infected cases spreads COVID-19 patient care equipment, and soiled linen; Environmental cleaning; Prevention of needle-stick/sharp infections in healthcare facilities. injuries; and Appropriate Health Care Waste Management (See Annex V: Standard Precautions). ➢ In addition, health facilities should establish and apply Transmission based precautions (contact, droplet, and airborne precautions) as well as specific procedures for managing patients in isolation room/unit (See Annex V: transmission-based precautions and specific measures for managing patients in isolation room/unit). ➢ The hospitals and laboratories should develop a hazardous material management procedure that (3) Hazardous materials used and Same as (1) above generated during the provision of defines: inventory of hazardous materials in the health care facilities, proper labeling of hazardous COVID-19 diagnosis, care and treatment materials, safe handling, storage and use of hazardous materials, use of protective equipment services or during the vaccination procedure for managing spill, exposures and other incidents, procedure for reporting of incidents. program. ➢ Hazardous materials should be handled in accordance with the accepted practices. Only trained personnel should handle the materials and precautions taken when handling materials by using (4) Hazardous chemicals in the hospitals required protection equipment such as ventilation hoods and personal protective equipment. (See and health care centers are limited to Annex IV and V). small volumes of laboratory reagents, chemicals, solvents, medicinal gases etc. ➢ During vaccination, proper use and disposal of safety boxes as well as safe disposal of syringes, vials and PPE according to WHO guidelines 158 ➢ Contractors and MOH should ensure that contracted workers and MOH and other relevant project (5) Workers, in particular females (the The issues related to brunt of the health sector), do not receive staff, have medical insurance and/or are able to receive free treatment of Covid-19. construction will be the care needed if infected with Covid-19, ➢ All workers must be paid for overtime as per Labor Law (December 2013 a Labor Law). considered during the or fear not getting it and continue to show ➢ Ensure that the staff with lower qualification or less experienced working in the health sector (e.g., preparation of up to work even with symptoms. cleaners, part-time workers, etc.), often female workers, also have access to the required Personnel various plans by Protection Equipment (PPE) and training to make sure they work in a safe environment. (6) Workers may be asked to work Contractors. ➢ Most vulnerable workers should be identified, such as female single heads of household, who may overtime to respond to the COVID-19 pandemic. It is important that these need additional support in order for them to do their job (for instance, female nurses who are single personnel are able to access overtime heads of household may need additional support if they have to work overtime). Additional support pay as needed. Women may in particular to consider may include cash grants, access to food support or provision of child care services. need to be provided with extra support if ➢ Health care workers must be actively supported by their employers and commended for their work, they are single heads of household and as well as offered psychological, emotional or mental support if possible. This may mean bringing also have child-care duties. in monks to a hospital for a ceremony, or ensuring health workers have regular breaks and proper (7) Health workers may face mental food throughout the day. issues or burnout as result of an ➢ All workers involved in upgrading facilities, health workers, cleaners, etc., must be reassured that outbreak. they will continue to get paid if they need to self-isolate if they are showing with COVID- 19/respiratory symptoms. These provisions must be made including for contracted staff and are (8) Minor risk of underage workers included in the Labor Management Plan (LMP). working as cleaners in medical facilities ➢ Child labor or indentured labor is absolutely prohibited in the project. All medical staff, cleaners, or transporting medical supplies or and all others handling equipment, tests, wastes, etc. or involved in the transportation of medical equipment. Labor law prohibits anyone equipment and supplies related to the project must be over 18 years. under 18 years to be involved in hazardous work. ➢ Any medical or other hospital staff (including cleaners) experiencing symptoms of COVID-19 or a respiratory illness (fever + cold or cough) must remain at home/isolated and report symptoms (9) Risk of GBV/SEA to workers and immediately to supervisors. community ➢ Training on community interaction and GBV/SEA to be provided for all teams, staff (civil servants (10) Risk of workers facing punitive and outsources staff/contractors) to ensure the teams respect local communities and their culture measures if they refuse vaccination and will not involve in misconduct. Signing of Code of Conduct. ➢ Workers must have the right to refuse the vaccine if they so choose. GOL immunization law prohibits force vaccination. However, All Workers will be encouraged to be fully vaccinated (at least two doses) before they can implement their works within the project”. 159 ➢ Communication materials and outreach to people must make clear that all treatment for COVID-19, (11) Social exclusion in particular of the The issues related to most vulnerable and marginalized and the vaccination program, at provincial/referral hospitals is free and accessible for all construction will be groups (elderly people; children, population. People must also be told about the GRM process to denounce any instance where they considered during the particularly those that are malnourished; are denied medical care or when they are not able to receive the vaccine even if they are in a priority preparation of those with underlying health conditions group. various plans by e.g. diabetes, cancer, hypertension, ➢ Stakeholder Engagement Plan (SEP) should ensure consultations with NGOs and other stakeholders Contractors. coronary heart diseases, and respiratory that can provide recommendations on how to reach vulnerable groups, as well as how to reach diseases, among others; persons with priority groups for the vaccination program. disabilities including physical and mental health disabilities; single parent headed households, male and female; poor, economically marginalized, and disadvantaged groups; and ethnic groups.) ➢ Hospitals and other health facilities must ensure they still have adequate staff to deal with ongoing (12) Focus on COVID-19 may redirect The issues related to staff and resources at health facilities medical needs. While non-urgent cases may be deferred, it is important that childhood vaccinations construction will be and negatively impact other areas, such continue, that women have prenatal and antenatal visits, that sexual and reproductive health services considered during the as maternal health check-ups, are available and that those with chronic conditions and/or disabilities continue to receive necessary preparation of vaccinations for children and treatment treatments (with adequate measures to separate from patients with COVID-19, as detailed in other various plans by of chronic diseases. This may sections in this Table). Contractors. particularly impact women, young ➢ Communication materials must stress that these normal services are still being provided, and explain children, those with chronic conditions, measures taken in health centers to avoid COVID-19 risks as there may be apprehension from HIV/AIDS and the elderly, among others. community members to go to health facilities. These groups of people, among others, may also be fearful of going to the hospital/health center for fear of contracting the virus. This may cause children to miss out on needed vaccinations, women not seeking support during pregnancy, etc. 160 ➢ Identification of disadvantaged and vulnerable groups in project areas will be made with a view to (13) There is possible social Same as (1) above discrimination/stigmatization against provide equitable access to the identification and diagnosis services. Priority groups for vaccination some vulnerable groups (the poor, the should have access to the vaccine regardless of ethnicity, gender, religion or income status. elderly, those with preexisting ➢ Information on how to protect oneself from Covid-19, the symptom of Covid-19 infection, where and conditions, and religious minority how to get tested should be made available and accessible to minority groups, other vulnerable groups) in the delivery of identification groups and the elderly by using different languages (including sign language and pictorial), and in and diagnosis services. a manner that is culturally appropriate to their respective groups and specific needs. Also disseminate information related to community health and safety, particularly around social (14) Health workers (disproportionally female), may face discrimination and distancing, hand washing, high-risk demographics, self-quarantine, and mandatory quarantine. harassment when going back to their ➢ Communication materials must reinforce the positive contribution of health care workers and make communities due to people’s fear in clear the steps health workers and other staff are taking to protect themselves against the virus and contracting the virus, frustrations over their use of PPE. medical care or misinformation. (15) Given scarce resources available, some vulnerable groups (the poor, the elderly, those with preexisting conditions, and religious minority groups) may be excluded from the quarantine, isolation, treatment services or excluded from accessing the vaccine. Table A6.3. Risk, Impacts, and Proposed Mitigation Measures during Procurement of Goods (Per the generic guideline/template provided in the Project ESMF Annex III Table A3.2) Risks and Impacts Proposed Mitigation Measures Responsibilities ➢ Projects should ensure that adequate handwashing facilities with soap (liquid), water and paper (1) Surfaces of imported materials may PCO, DHR, DHHP, towels for hand drying (warm air driers may be an alternative), plus closed waste bin for paper be contaminated and handling during towels are available. Alcohol-based hand rub should be provided where handwashing facilities PHO/DHO, and HCF transportation may result in spreading. cannot be accessed easily and regularly. owners ➢ Also ensure awareness campaigns and reminder signs are regularly posted around site to encourage workers regularly wash hands when handling goods, and that they do not touch their face. The 161 awareness campaigns and signs should be designed different languages and in a manner that is culturally appropriate, and accessible to ethnic minorities groups, vulnerable groups and elderly. ➢ If concerned (for example when dealing with goods that have come from countries with high numbers of infected people) a surface or equipment may be decontaminated using disinfectant. After disinfecting, workers should wash hands with soap and water or use alcohol -based hand rub. A label containing information on how materials/medical facilities/equipment should be safely handled should be available on site. ➢ The healthcare workers shall be provided with medical personal protective equipment (PPE) (2) Incorrect standard or quality of PPE Same as (1) above leads to spread of virus or other germs to including: Medical mask, Gown, Apron, Eye protection (goggles or face shield), Respirator (N95 healthcare workers and cleaners or FFP2 standard), Boots/closed work shoes ➢ WHO interim guidance on rational use of PPE for coronavirus disease 2019 provides further details on the types of PPE that are required for different functions. ➢ The project health facilities should establish and apply procedures for use of PPE in line with WHO guidelines and National guidelines for Infection Prevention and Control healthcare facilities Information/instruction on how PPE should be used safely handled and should be made available on site. (See Annex V). ➢ Contractors and MOH should ensure that contracted workers and MOH and other relevant project staff, have medical insurance and/or are able to receive free treatment of Covid-19. ➢ Project health facilities should ensure that adequate handwashing facilities with soap (liquid), water (3) Inadequate handwashing facilities Same as (1) above are provided for handling. and paper towels for hand drying (warm air driers may be an alternative), plus closed waste bin for paper towels are available. If water and soap handwashing facilities are not possible, alcohol-based hand rubs may be provided. ➢ The project health facilities should establish and apply procedures for hand hygiene in line with WHO guidelines and National guidelines for Infection Prevention and Control healthcare facilities Sign boards on how to do proper hand wash should be stick at each hand wash stations. ➢ Alcohol-based hand sanitizers are not considered as effective as hand washing with soap and water, (4) Alcohol-based hand rubs may not be Same as (1) above as affective at controlling infection as and should therefore only be used in locations where full hand washing facilities cannot be provided. hand washing with soap and water. Advice should be provided to remind users where full handwashing facilities can be found. ➢ The project health facilities should establish and apply procedures for hand hygiene by alcohol in line with WHO guidelines and National guidelines for Infection Prevention and Control healthcare facilities Sign boards on how to do proper hand wash should be stick at each hand wash stations. 162 ➢ The treatment of healthcare wastes produced during the care of COVID-19 patients should be (5) Wastes from vaccination programs or Same as (1) above treatment are not properly dealt with and collected safely in designated containers and bags, treated and then safely disposed. lead to further infection. ➢ Open burning and incineration of medical wastes can result in emission of dioxins, furans and particulate matter, and result in unacceptable cancer risks under medium (two hours per week) or higher usage. Single-chamber, drum and brick incinerators do not meet the BAT requirements under Stockholm Convention. Small-scale incineration should be viewed as a transitional means of disposal for health-care waste. If small-scale incinerators are the only option available, the best practices possible should be used, to minimize operational impacts on the environment. ➢ Alternative treatments should be designed into longer term projects, such as steam treatment methods. Steam treatment should preferably be on site, although once treated, sterile/non-infectious waste may be shredded and disposed of in suitable waste facilities. ➢ The project health facilities should establish and apply procedures for healthcare waste management in line with WHO guidelines for Safe management of wastes from health-care activities and National guidelines for Infection Prevention and Control healthcare facilities. ➢ Attention should be given to the distribution system, to ensure effective and efficient use of the goods (6) A non-transparent and poorly Same as (1) above managed distribution system and and services and avoid capturing of the rich, powerful and privileged, particularly at this time of practice could worsen the current short supply. shortage situation, affecting the Particular attention and efforts should be given to the disadvantaged and vulnerable groups and maximum and efficient use of resources. ethnic IP communities to make sure that they have equal if not better access to these resources. The disadvantaged and vulnerable population groups, and IP communities could face disproportionate difficulties in accessing the available resources, exposing them to greater risks. 163 Table A6.4. Risks, Impacts, and Mitigation Measures associated with Technical Assistance and Training during Operational Phase (Per the generic guideline/template provided in ESMF Annex III Table A3.3) Risks and Impacts Mitigation Measures Responsibilities ➢ TORs to include specific requirement for regular review of information and guidance, including (1) Information, advice, guidance and Ministry of Health training are not updated regularly as WHO, CDC and other governmental websites. (MOH) more becomes known about how the ➢ Refer to WHO, CDC websites and other locations as necessary to remain up to date on causes of spread and treatment of infected patients. (PCO and related virus responds to treatment and is departments at transmitted as well as vaccination national and protocols. provincial levels including hospital) ➢ TORs should require specific actions to be identified to ensure disadvantaged and vulnerable (2) Provision of support to the Ministry of Health disadvantaged vulnerable groups is not groups have effective identification, diagnosis and treatment, whether in medical facilities or in the (PCO and related included in the technical assistance and community, and how they can best access support and treatment and other related services. departments at capacity building program ➢ Similarly, where IP communities are involved, need to follow ESS7 and IPF policy Para 12 on national and emergency provision. provincial levels including hospital) ➢ Planning of containment measures and social restrictions need to take into account the livelihood (3) Planning and design of measures to Same as (1) above screen people for COVID-19 or for impact it will have for the population, in particular the most vulnerable. MOH and the Lao vaccination deployment and information government may need to develop specific mitigation measures for this, such as social safety nets with materials developed could exclude the cash transfers to specific population groups, ensuring that it does not exclude informal workers, the most vulnerable, who are also less likely poor, home-based workers, ethnic groups, etc. May also include food grants, essential basket of to have access or be active on social goods, child care support for women, etc. media. ➢ When developing communication materials, it is important to ensure that they are clear and concise, and that they are in a format/language that is understandable to all people, in particular the most (4) Restrictions on travel, general vulnerable. This includes ensuring there is access to pictorial materials that can be understandable movement, etc. have the potential to to ethnic groups, as well as materials for those with disabilities (audio for the blind, for example, or enhance negative impacts to the sign language for the deaf). Messages should be clear and concise, focusing on (i) hygiene measures vulnerable groups, who may have lower and how to protect against COVID-19 (hand washing, coughing, social distancing), (ii) symptoms incomes, lose jobs, have childcare duties, of COVID-19, (iii) what to do if suspect have COVID-19, as well as (iv) restrictions if applicable 164 and may also be the most vulnerable to (for instance specific guidelines on social-distancing). There should be a dedicated hotline for people contracting COVID-19. to call for questions and recommendations on what to do if they suspect they may have COVID-19. ➢ Different media needs to be used (social media, radio, tv) plus engaging existing formal and informal (5) Communication materials may not Same as (1) above reach the most vulnerable. public health and community-based networks (schools, healthcare service providers at local level, etc.). Social influencers should be utilized, such as religious monks, ethnic group chiefs, celebrities, NGOs, or other people with influence, who can help to disseminate the information messages. (6) General population may lack of ➢ A focus of information materials should be on women, as they tend to be the best venue of understanding in about how COVID-19 communication for children and the elderly in the household. is contracted. ➢ Communication materials must stress that these normal services are still being provided, and explain measures taken in health centers to avoid COVID-19 risks as there may be apprehension from community members to go to health facilities. (7) Vulnerable groups, in particular ➢ Hand washing messages should be clearly promoted in all provinces/districts. Those with women, may have difficulties in restrictions in accessing water or soap should be assisted by district and/or village chiefs. accessing clean water, in particular during the dry season. ➢ Communication materials must be developed with the needs of ethnic groups in mind, including (8) Ethnic groups may be at heightened Same as (1) above risk if they contract COVID-19 due to making information available in pictorial manner as described in other sections in this Table. It their remoteness in accessing treatment would be important to consult with ethnic groups/organizations when developing these materials. (though their remoteness may protect ➢ In particular, ethnic groups and remote communities need to have access to concise information them from contracting the virus). They about how to i) avoid contracting COVID-19 and good hygiene; ii) COVID-19 symptoms; iii) what may also face difficulties in accessing the to do/what medical facilities to call or visit if experiencing COVID-19 symptoms; and iv) benefits of vaccine. the vaccine; v) priority groups for the vaccine and vi) how to access the vaccination program. A focus for ethnic group and remote communities should also be on steps to take when traveling outside Their location may also make the diagnosing and treatment of the virus of their area, and potential measures for self-isolation for members that have been in areas with more difficult. documented COVID-19 cases, in order to protect remote communities. ➢ Project workers must take extreme cautionary measures if visiting remote and/or ethnic communities They may also be unable to access as they could risk bringing the virus to very remote areas. reliable information materials, including ➢ Medical attention to ethnic groups must be sensitive to their needs. on vaccination, or in a manner that they ➢ Vaccination program must take into account the needs of ethnic groups, including access, language understand them, or may have traditional and traditional beliefs that may result in supply and demand barriers to vaccination. 165 beliefs that are in conflict with medical information. ➢ Communication materials should be focused not only on hand washing and hygiene, but on how to (9) Quarantine measures, together with Same as (1) above fears over COVID-19, livelihood impacts cope with social and mental aspects of the COVID-19 pandemic, including loss of jobs and as a result of any restrictions in quarantine measures. For instance, there should be information on how to cope with stress and movement, social isolation and increased anxiety, recommendations on how to talk to children, etc. Information materials should provide links economic pressures and loss of jobs to resources/organizations that can provide support. (informal or formal sector) may ➢ Engage social influencers, such as religious leaders, who can help communicate accurate messages, exacerbate household tensions and lead including on vaccination benefits. to an increase in GBV and VAC. ➢ Stakeholder Engagement Plan (SEP) should ensure consultations with CSOs, women, women’s (10) School closures would mean groups and other stakeholders that can provide recommendations on how to communicate children are at home and this could information with vulnerable groups, how to support women, and on topics such as GBV and VAC. increase risk of VAC and GBV, in ➢ There is a need to ensure that GBV-resolution mechanisms and GBV and other mental health particular if family members are services continue to be well resourced as there may be increased demand for their services stressed, drinking or violent. Young ➢ Apply the WHO Code of Ethics, Codes of Conduct and ESS COP attached in this ESMF for all females may be in particular risk. workers in the quarantine/isolation facilities, as well as the provision of gender-sensitive infrastructure, such as segregated toilets and enough light in quarantine and isolation centers. (11) Women are more likely to be informal or self- employed workers than ➢ ESS COP included in the letter of PCO’s staff appointment and contracts (for contracted workers) men, and may lose income as a result of in line with relevant national laws and legislations and the project’s Labor Management Procedures containment restrictions to prevent (LMP), including for those working on contact tracing or any other in contact with local COVID-19. communities. ➢ Training on community interaction and GBV/SEA to be provided for all teams, staff (civil servants (12) Women may also have increased and outsources staff/contractors) to ensure the teams respect local communities and their culture pressures in the home to look after the elderly and young children, especially if and will not involve in misconduct. Signing of Code of Conduct. there are school closures. ➢ Lao government may need to consider ways it can support women during the COVID-19 pandemic, in particular female health workers, ensuring continuity of care for sexual and reproductive health, (13) Women who are single heads of and potential for additional support to women losing income, in particular if in the informal sector households may be under increase (this could be in the form of cash grants, food support or other support). strains if they lose jobs. ➢ Lao government may need to think about measures to support informal workers if they experience significant livelihood loses. While women are a big part of the informal workforce, men must also be considered. 166 ➢ Ensure consultations on SEP and this ESMF include relevant government agencies, NGOs and other (14) If stakeholders are not properly Same as (1) above consulted, information is not disclosed organizations working on health and gender, including GBV, as well as ethnic groups. and people are not informed about their ➢ Ensure messages relating to COVID-19, including on vaccination, reach all groups of people, in rights, options for grievance redress or particular the most vulnerable (as defined in this Table). This may include having a multi-faceted project timelines, there could be approach to consultations and disclosure of information and information sharing, such as by misunderstandings, conflict, stigma, loudspeaker (by district health authorities), Facebook, SMS, You Tube videos, social false rumors or loss of confidence in the influencers/religious leaders, etc. community regarding the project. ➢ Ensure communication materials not only focus on COVID-19 symptoms and hygiene, but also on coping strategies if there is social isolation, avenues (materials, organizations, hotline) available for mental health, GBV, etc. that may be available. ➢ Also see other recommendations on communications materials and messages outlined in this Table. ➢ When developing communication messages about COVID-19, it is important to have social stigma (15) Risk of fear and/or stigma towards Same as (1) above the virus, which may make people hide issues in mind and choose language that does not exacerbate stigma. It is best to not refer to people symptoms, avoid getting tested and even with the disease as “COVID-19 cases”, “victims” “COVID-19 families” or “the diseased”. It is reject hygiene measures or wearing PPE better to refer as “people who have COVID-19”, “people who are being treated for COVID-19”, equipment (or masks if recommended) or “people who are recovering from COVID-19”. It is important to separate a person from having an identity defined by COVID-19, in order to reduce stigma. This language should be used (16) Health workers may suffer stigma, in throughout all communication materials. particular when coming back to their ➢ Engage social influencers, such as religious leaders, who can help communicate accurate messages communities, as they may be seen as potential “carriers” and help to reduce social stigma as well as support those who may be stigmatized. ➢ Ensure accurate information about the virus is widely disseminated, and that there is also a focus (17) Some groups may be particularly on people recovered. One way to do this could be through District health officials and/or village vulnerable to stigma, such as IP groups, chiefs. They could be trained or provided accurate information on the basics of COVID-19 people coming back from Thailand and prevention (good hygiene, frequent hand washing, avoid touching face, social isolation measures) foreigners. and be provided with simple materials in Lao language as well as pictorial. ➢ Communication materials must reinforce the positive contribution of health care workers and steps they are taking to protect themselves against the virus and their use of PPE. (18) Screening of people entering the Law enforcement personnel must adhere to highest professional standards when carrying out their Same as (1) above country, in particular land borders as duties. well as contact tracing, confirmation of The law enforcement personnel are GOL staff who are responsible for exercising measures related to cases or enforcement of any community GOL enforcement measures to control COVID-19 according to their roles and responsibilities, especially movement restrictions or 167 quarantine/lockdown or social those related to lock down, curfew, and illegal border enforcement. GOL higher officers who are restriction measures, could lead to abuse responsible for such enforcement will hold their staff accountable. of power by law enforcement, fear from community members (especially the elderly, ethnic and marginalized groups), a potential for GBV, Sexual Exploitation and Abuse (SEA) and/or VAC. 168 Attachment 2. Infection Prevention and Control Procedures (IPCP) and Healthcare Waste Management Procedures (HCWMP) 1. This Attachment is prepared in accordance with the technical guidance on Infection Prevention and Control Procedures (IPCP) and Healthcare Waste Management Procedures (HCWMP) provided in the Project ESMF Annex IV. They will be discussed among agencies during the update of MOH regulations and/or SOP related to IPCP and HCWMP. 2. Section 6B.1 (IPCP) provides technical guidance on (i) Hand hygiene procedure, (ii) Respiratory hygiene, (iii) Personal protective equipment procedures, (iv) Patient-care equipment cleaning and disinfection procedures, (v) Soiled linen management procedures, (vi) Environmental cleaning procedure, (vii) Prevention of needle-stick/sharp injuries, (viii) Contact precautions, (ix) Droplet precautions, (x) Air-borne precautions, and (xi) Specific procedures for managing patients in isolation unit. Section 6B.2 provide procedures on healthcare waste management procedures. It is noted that under this section, MOH guidelines on solid waste collection (bins color) has been adopted while those related to wastewater treatment has also been considered during the detailed design of the sewage and wastewater treatment system (SWWT) for the proposed HCF. Section 6B.1 IPCP (a) Hand hygiene procedure 2. HCFs staff and care givers should perform hand hygiene, when arriving at work/HCFs and before leaving work/HCFs, as well as before eating and after using the toilet/ latrine. Additionally, for anyone who is providing care to patients, the “Five moments for hand hygiene” must be respected. 169 (b) Respiratory hygiene 3. Respiratory hygiene and cough etiquette is a standard precaution that should be applied by all patients, visitors and HCWs to contain respiratory secretions (e.g. when coughing, sneezing…) to avoid spreading respiratory infections. 170 4. HCF should promote respiratory hygiene and cough etiquette by: • Educating HCF staff, patients, family members, and visitors on the importance of containing respiratory droplet/ aerosol and secretions to prevent the transmission of infectious disease (e.g. influenza, tuberculosis, bacterial pneumonia …). • Posting signs informing that patients and family members with acute febrile respiratory illness use respiratory hygiene/cough etiquette (e.g. poster). • Prepare equipment in triage area for patient and family to apply respiratory hygiene. For instance, in Out-Patient- Department (OPD) and Emergency Room (ER), make mask, tissue, rubbish bin, and etc. (c) Personal protective equipment procedures 5. These procedures will be applied to all healthcare workers 171 172 173 (d) Patient-care equipment cleaning and disinfection procedures 6. All medical devices are either single-use or reusable ones. Single-use equipment must be discarded, while all reusable equipment must be properly processed between use and between patients, to prevent infections. For proper reprocessing of equipment, all items need to be cleaned with detergent (liquid soap) and water before disinfection and sterilization, to get rid of the organic matter e.g. blood and mucus that may neutralize chemical disinfectant and affecting the efficiency of the disinfectant. 7. Instruments and other items may be classified based on the risk of transmitting infection into critical, semi-critical or non-critical, depending on the sites. Patient-care equipment cleaning procedure • Prepare all cleaning and disinfecting equipment and solution • Cleaning staff wear PPE: rubber gloves and boots, impermeable apron. when there is a risk of splash in the face, staff must wear eyes protection and surgical mask. • Take off any gross soiling on the instrument by rinsing in clean water • Take instrument apart – fully and immerse all parts in detergent solution, and clean all channels and bores of the instrument • Ensure all visible soil is take off from the instrument – follow manufacturers’ instructions, • Rinse thoroughly with clean water • Dry the instrument (let it dry to– on a clean rack or hang if tubing or items with lumens/flueorescent, away from other dirty items) • Inspect to ensure the instrument is cleaned 174 Patient-care equipment disinfecting procedure • Prepare disinfectant solution according to the volume of medical instruments, following notice of disinfectant, cleaning staff wearing PPE at all time while implementing cleaning works. The following table shows the most common sources of chlorine in Lao PDR, and the amount of water to add to obtain a 0.5% or 0.05% solution. • Immerse the cleaned equipment completely in the disinfectant solution. Soak in the solution, duration will depend on the disinfectant recommendations and dilutions. For example: Sodium hypochlorite 0.05%: soak during 30 minutes • Rinse thoroughly with clear or sterile water (depending on the required level of disinfection and the use of the equipment) • Sterile water for semi-critical instrument (HLD) • Clean water for non-critical instrument (low level of disinfectant) • Let it dry (on a rack) • Pack the disinfected equipment and store in a clean area (e) Soiled linen management procedures 8. Soiled linen, from patients and HCWs should be cleaned, and disinfected/ sterilized when necessary in HCF laundry. To ensure a safe and sanitary environment for laundry staff, PPE should be available, as well as the supply of clean water, and provision of a hygienic laundry location. 9. The basic principles of linen management are as follows: • In laundry room, the staff should be protected and wear at least: gloves, surgical mask, and impermeable apron, and close shoes or rubber boots. Where there is no laundry 175 machine, and staff is washing by hands, the staff need to wear eyes protection (e.g. safety glasses) • Place used linen in bag for linen at the point of generation. Do not rinse in patient care area. • Any linens soiled with blood/bodily fluid are considered infectious and must be disposed of accordingly. • Separate infected linen from non-infected linen and put it in a bag for infectious linen (e.g. yellow impermeable bag). Keep it separated during transport. • Handle all linen with minimum agitation to avoid aerosolization of patho-genic microorganisms. • Mattresses and pillows should be covered with plastic and be wiped over with a neutral detergent (refer to environment cleaning). If there is no plastic cover, wash them by hand. 9. Principles for reprocessing soiled linen: Non-infectious linen Infectious linen Infectious drapes from operating room Overview 4 Linen from non- 5 All linens from 6 All drapes from infectious patient and infectious patients and/ or with operating room are without blood/ body fluid blood/ body fluid infectious. PPE required Disposable gloves 7 Disposable gloves 8 Rubber gloves when (Other PPE may be required (Other PPE may be required handling linen depending on route of trans- depending on route of trans- mission. mission) Sorting used 9 Place in bag for 10 Place all used linen in 11 Place all drapes in linen linens. Separate linens bag for infectious linen (e.g. bag for infectious linen (e.g. soiled with bodily fluid and yellow impermeable bag) at the yellow impermeable bag) at put in infectious linens bag. point of gene-ration the point of generation. PPE required 12 Gloves Surgical 13 Rubber gloves; 15 Rubber gloves; in laundry mask; Impermeable apron; Surgical mask Surgical mask; Eye room, when Close shoes or rubber boots 14 Eye protection; protection; Impermeable using laundry Impermeable gown or non- gown or non-impermeable machine impermeable gown with gown with impermeable impermeable apron; Rubber apron; Rubber boots boots PPE required 16 Rubber gloves, 17 MUST NOT be hand 19 MUST NOT be in laundry eyes protection, surgical washed. If not laundry ma- hand washed. If not laundry room, for mask, impermeable apron chine available, wash by hands machine available, wash by hand washing rubber boots, with caution hands with caution 18 Always wear eyes 20 Always wear eyes protection when using protection when using disinfectant disinfectant Washing 21 Detergent 24 Detergent (Laundry 27 Detergent (Laun- process with (Laundry liquid or powder) liquid or powder) dry liquid or powder) hot water (at 22 Rinse 25 Rinse 28 Rinse least 70oC) 23 Dry (dryer or sun 26 Dry (dryer or sun & 29 Dry (dryer or sun & iron) iron) & iron) 30 Bring clean and dried drapes to the central of sterilization 176 Washing 31 Wash with deter- 34 Detergent (Laundry 38 Detergent (Laun- process with gent (Laundry liquid or liquid or powder) dry liquid or powder) warm or cold powder), 35 Rinse 39 Rinse water (less 32 Rinse 36 Soak in clean water 40 Soak in clean water than 70oC) 33 Dry (dryer or sun with sodium hypo-chlorite with sodium hypo-chlorite & iron) 0.5% for 30 minutes10 0.5% for 30minutes 37 Wash again with 41 Wash again with detergent and water, and dry detergent and water, and dry (dryer or sun & iron) (dryer or sun & iron) 42 Bring dried drapes for packaging and sterilization. 43 44 If there is no other 45 Note option (no laundry machine), for infectious linen/ surgical drape, before being wash by hand, they need to be decontaminated at first (soak in disinfectant solution e.g. bleach 0.05% or autoclaved), then they MUST be cleaned rinsed and disinfecting, and sterilization for sterile drapes, to avoid contamination of patient (f) Environmental cleaning procedure 11. Most areas of HCFs, are low risk zone (non-infectious zone), these areas should be cleaned daily, with detergent solution (soapy water) to remove dirt and organic material and dissolve or suspend grease, oil, and other matter so it can easily be removed by scrubbing. In high-risk areas where heavy contamination is expected and risk of cross-contamination by the staff and other patients, surfaces need to be cleaned with soapy water, rinsed, and let it dry, before being disinfected (e.g. sodium hypochlorite (chlorine) solution 0.05%). High risk are areas are for instance, operating rooms, pre- and postoperative recovery areas, intensive care units (ICUs), isolation room, laboratory, toilets and latrines; or area with blood/ body fluid spills. When cleaning, cleaners are at risk and need to be properly trained. They also must wear appropriate PPE, at least rubber gloves, rubber boots, uniform or apron. When there is risk of splash in the face, wear surgical mask and eyes protection. 12. Key procedures are as follows: Principles of Environmental Cleaning • Apply hand washing / hygiene and wear appropriate PPE (at least rubber gloves, rubber boots, uniform or apron. When there is risk of splash in the face, wear surgical mask and eyes protection). • Prepare fresh cleaning and household solution once a day; and change solution whenever they appear to be dirty. • Perform cleaning and disinfecting patient environment at least once a day. • Clean first with detergent (soapy water), rinse with water, let it dry in non-patient area (e.g. including corridor, laundry room etc.) 177 • In high risk area (patient care area), following cleaning procedure, disinfect surface by using household disinfectant (e.g. bleach 0.05% solution, alcohol 70% for small object, or follow manufacture recommendations). • Every day clean all patients’ rooms, units, cleaner’s rooms • Cleaning with a moistened cloth helps to avoid contaminating the air and other surfaces • Clean from the less contaminated to the most contaminated area (e.g. start from corridor, then patient’ room, and last finish to clean bathroom and toilet) • After patient discharge, clean and disinfect patient room very well, including all equipment that has been in contact with patient (e.g. bed, bed table…) as soon as possible • After use, all cleaning equipment (e.g. mop, brush, bucket, cloth…) must be cleaned, disinfected and dried before storage, and be reused. • In general, do not spray (i.e. fog) occupied or unoccupied clinical areas with disinfectant. This is a potentially dangerous practice that has no proven disease control benefit. Cleaning up Spills • Clean up spills of potentially infectious fluids immediately, to preventing the spread of the infection and also prevents accidents. • Small spills of blood of other body fluids should be wiped with paper towel (staff using disposable gloves), then clean with soapy water, rinse and disinfect. Appropriate handling of bedding • Mattresses and pillows with plastic covers should be cleaned with deter-gent, after departure of each patient. • In isolation unit and intensive care unit, as well as infectious wards (e.g. TB..) disinfecting should follow cleaning procedure. (g) Prevention of needle-stick/sharp injuries 13. In healthcare settings, injuries from needles or other sharp instruments are the number- one cause of occupational exposure to blood-borne infections. All staff that come in contact with sharps - from doctors and nurses to those who dispose of the trash - are at risk of infections. Improper disposal of sharps also poses a great threat to members of the community. 14. The term sharps refers to any sharp instrument or object used in the delivery of healthcare services - including hypodermic needles, suture needles, scalpel blades, sharp instruments, intravenous (IV) catheters, and razor blades. Needle stick/sharp injury means the skin is accidentally punctured by a used needle/ sharp (e.g. scalpel). The injury is a port of entry for blood-borne diseases, such as hepatitis B (HBV) and hepatitis C (HCV), HIV etc. Exposure to patient’s body fluid also put HCWs at risk of infection. Therefore, they are encouraged to strictly comply with IPC precautions related to body fluid. 15. Key procedures are as follows: The main causes of needle stick/sharp injury include: • Recapping of needles (identified as the most common cause) 178 • Unsafe handling of sharp waste (identified as the second most common cause) • Reuse of safety box • Manipulation of used sharps (bending, breaking, or cutting needles). • Unnecessary injections • Lack of supplies: disposable syringes, sharps-disposal container/safety box • Failure to place needles in sharps containers immediately after injection • Passing sharps from hand to hand (e.g. during surgery) • Lack of management of sharp wastes • Lack of awareness of the problem • Lack of training for staff Principle of the disposal of used needles/sharps • Never recap needle/sharp • Dispose of needles and syringes immediately after use in the safety box. • Close the safety box, whenever the containers become ¾ full. • Safely dispose the safety box (e.g. via incinerator with temperature at least of 800 o Celsius) • When it is not immediately disposed, keep safety boxes in appropriate storage, for infectious waste. Refer to “Healthcare Waste Management Guidelines 2011” and “National Injection Safety Guidelines 2014”, for more information. Safety Box or Sharp disposal container • Safety boxes MUST be puncture and leak resistant. They should be conveniently located in any area where sharp objects are frequently used (such as injection rooms, treatment rooms, operating theatres, labour and delivery rooms, and laboratories). 179 (h) Contact precautions 16. Procedures are as follows: (i) Droplet precautions 17. Procedures are as follows: 180 (j) Air-borne precautions 18. Procedures are as follows: (k) Specific procedures for managing patients in isolation unit 19. Preparation of isolation Room / unit • Isolate infectious patient in a single room • If there is no single room, isolate in the cohort room. In cohort room, always keep suspected cases separate from confirmed cases 181 • If single and cohort room, keep the single room for suspected cases and the cohort room for confirmed cases • Avoid movement of infectious suspected and confirmed patients (only if crucial) • Limit number of visitor (ideally only one) • Staff help the visitor select PPE base on route of transmission, visitor must be trained for wearing PPE • Put a clear sign of restrictive area and fence around isolation room/unit • Set up isolation room/ unit as per standard • Prepare the isolation room and ensure refurbishment of PPE/ material. 20. The following items should be kept on the trolley at all times so that PPE is always available for healthcare workers 21. HCWs/staff in the isolation room /unit • Apply IPC standard and adequate additional precaution(s) based on route of transmission • For emerging infectious disease (EID), with unknown route of transmission, apply standard precautions and all additional precautions (contact+ droplet+ airborne), until the route of transmission has been identified (staff will wear FULL PPE, maximum protective personal equipment) • Exclusively assigned trained staff (medical and non-medical) ⁺ If HCW is not trained, he/she must not wear PPE and enter in the isolation room • Prior entering to the room: ⁺ HCW must record their name and contact details ⁺ Perform hand hygiene and wear PPE for identify route of transmission (following PPE procedure) • After contact with isolated patient: ⁺ HCW must safely take off PPE, and thoroughly wash hands precautions (following PPE procedure) 182 22. PPE Procedure in Isolation room/ unit • The PPE to wear will depend on the type of isolation precautions; therefore several PPE procedures are possible. Keep in mind the steps of removing the PPE (from more contaminated to less), this will guide the step of putting on the PPE. • Example of PPE procedure when all PPE items are needed (based on assessment of the risk and route(s) of transmission. 183 23. Environment Cleaning / Disinfecting • Trained staff is wearing PPE depending on route of transmission, adding rubber gloves, impermeable apron, rubber boots. ⁺ In isolation room, all surfaces (floor, table…) need to be cleaned, than disinfected once per day. • When heavy contamination (blood, vomit, faeces) on surface and floor, take off spill, clean with detergent, disinfect with chlorine solution 0.5%. • Refer to the list of disinfectant to select those that will inactivated the pathogen. The most common hospital disinfectant include: ⁺ Sodium hypochlorite (household bleach); ⁺ Ethyl alcohol 70%; ⁺ Phenolic compounds; ⁺ Quaternary ammonium compounds; ⁺ Hydrogen peroxide • Refer to dilution table, to prepare the detergent disinfectant solution. • Some disinfectant solution, provide the two actions (detergent and disinfectant) in one product, follow instruction for that specific product. 24. Reprocessing reusable equipment • Clean with detergent, then soak into chlorine solution 0.05% for at least 30 minutes, rinse and let it dry in a clean area. 184 • If using google or safety glasses, clean with detergent, then soak in chlorine solution 0.05% for 10 minutes (30 minutes can damage the goggle, glasses), thoroughly rinse (avoid irritation of eyes) and let it dry in a clean area, before reusing. • Refer to the Preparation of Sodium Hypochlorite Solution Procedure. • Contaminated equipment should be placed in clearly-labelled, leak-proof bags or closed container. • Transport of equipment bag/container from the anteroom to the cleaning/ utility room ⁺ The trained staff wears disposable gloves and mask to transport the bag to the cleaning room. ⁺ Place the leak-proof bag into a new bag (double bag) or ⁺ Disinfect the outside part of the container with e.g. chlorine solution 0.05% ⁺ Use a wheeled bin with a lid or trolley (covered trolley is preferred) to transport the bag. The staff must not carry the bag/container. ⁺ Clean and disinfect all surfaces of the trollies or bins, after each use • Cleaning staff, like other staff need to check and record their temperature twice a day, and notify to chief of unit or IPC team, if any symptoms. 25. Soiled linen: • Soiled linen must be proceeding by trained staff wearing PPE (depending on the pathogen route of transmission). At least wear rubber gloves, impermeable apron, and rubber boots (refer to Appendix 1D appropriate handling of soiled linen) • Wash with detergent and disinfect linen daily. • If there is any solid excrement such as faeces or vomit, ⁺ Remove carefully, and flush it down the toilet (if proper sewage connection) or in the sluice before linen is placed in its bag or container. ⁺ If not proper sewage connection, remove carefully, discharge in waste bag, ⁺ or decontaminate with disinfectant solution (concentration depending on the pathogen) • Soiled linen should be placed in clearly-labelled, leak-proof bags or closed container. • Transport of linen bag/container from the anteroom the laundry room ⁺ Place the leak proof bag into a new bag (double bag) or ⁺ Disinfect the outside part of the container with e.g. chlorine solution 0.05% ⁺ The trained staff wears disposable gloves and mask to transport the linen bag to the laundry ⁺ Use of a wheeled bin with a lid or trolley (covered trolley is preferred). The staff must not carry the bag/container. ⁺ Clean and disinfect all surfaces of the trollies or bins, after each use • In the laundry room, trained staff wear PPE wearing PPE depending on the pathogen route of transmission, with rubber gloves, waterproof apron and rubber boots), wash infected linen with laundry machine: ⁺ In hot water of 70⁰C: wash with detergent or disinfectant (30 minutes). ⁺ In cold water (< 70⁰Celsius): wash with detergent, then disinfectant that are active in cold water. When using bleach, rinse in clean water, and dry before reuse. 185 • Laundry staff, like other staff need to check and record their temperature twice a day, and notify to chief of unit or IPC team, if any symptoms 26. Management of Infectious Waste • Only trained staff, wearing PPE depending on the pathogen route of trans-mission, with rubber gloves, impermeable apron and rubber boots, must handling infectious waste in the isolation room/ IU (see Appendix 2 Transmission based Precautions) • Dispose needle/sharps in a sharp-proof container (as per standard precautions), and never re-cap needles and/or separate needle from syringe before disposing in the container. • Dispose infectious waste in a “biohazard” labelled waste bag, or leak-proof waste bag (refer Appendix 1G HCWM) • Management of solid infectious waste • Transport of infectious waste bag from isolation room/ unit to incinerator or designated pit: ⁺ Put the waste bag in another clean bag (double bagging) before exiting the isolation area or decontaminate container/bag with the infectious waste, with chlorine solution 0.05%. ⁺ Outside the isolation area, staff who is helping for double bagging, trans-port the decontaminated bags/containers, should wear at least gloves and disposable mask if outside the isolation zone. • When storing bag/container with infected waste, before being properly manage ⁺ Do not stored them more than 24 hours ⁺ The store place must be protected by a fence to prevent entry by animals, children, or untrained personnel • Management of waste bags with infected solid waste ⁺ Incinerate bags with infectious wastes (high temperature > 800oC.) ⁺ Disinfect infectious waste by autoclave ⁺ Bury in a designated pit of sanitary landfill • Management of infected liquid waste (blood, feces, urine and vomit, grey water, etc.) • With adequate PPE, depending on the pathogen route of transmission, adding eyes protection and surgical mask (if not worn) ⁺ Flush liquid waste (e.g. urine, liquid faecal waste) into the sewage system, if there is an adequate system in place. ⁺ Avoid splashing when disposing of liquid infectious waste to avoid possible generation of aerosols • When hospital does not have an adequate system ⁺ Select adequate disinfectant solution for the pathogen ⁺ In general, disinfect liquid waste with chlorine 0.05% or 0.5% depending on the pathogen before disposing (e.g. disinfect cholera with chlorine solution 0.5%) • Avoid splashing when pouring disinfectant solution 27. Handling of dead bodies • Discourage any local practices (touching/ being in contact with the corpse) by HCW, family, friends... • Dead body remains should not be sprayed, washed or embalmed. • PPE to safely handle dead body. Refer to route of transmission, with at least: ⁺ Disposable gown with long-sleeves 186 ⁺ Waterproof apron ⁺ Disposable, non-sterile gloves (over the cuffs of the gown) ⁺ Surgical mask (wear particulate mask if autopsy) ⁺ Eyes protection (preferable face-shield, or goggle) ⁺ Rubber gloves ⁺ Rubber boots • Put corpse in waterproof/ impermeable body bag immediately; and transfer to the mortuary as soon as possible after death. • Bury or incinerate corpse without delay • Surveillance of staff who handle dead body (need to check and record their temperature twice a day, and notify to chief of unit, IPC team if any symptoms) 28. Occupational health • Any staff and visitor who is entering in the isolation room/ isolation unit (IU), or has any contact with contaminated equipment, linen, waste, dead body MUST: ⁺ Register their name and contact details in the log book of isolation room/ unit, for contact tracing purpose. ⁺ Follow up health status, fever and other symptoms (refer to suspect case definition/ triage form) ⁺ Take and record temperature twice daily, for the entire incubation period after the last contact ⁺ Notify to chief of unit, IPC team, focal point if any symptoms • Have a good hygiene, drink plenty of safe drinking water, and rest to avoid mistake due to overwhelmed, severe fatigue. • Provide supervision and support from chief of IU, IPC focal point and director of hospital • Promote preventive medicine: ⁺ No pregnant women should be working in isolation room/ unit ⁺ Provide psychological support to the staff/team who work in isolation room/ unit ⁺ Prevent heat illness/ dehydration (serious risk of heat illness while wearing PPE in tropical conditions) • For HCWs who are developing symptoms • Stop work immediately or do not report to work • Limit interactions with others • Exclude themselves from area, • Notify the chief of unit or focal point if any fever > 38°C. and/ or other symptoms (refer to case definition) • Exposed persons must receive follow-up care (e.g. antiviral therapy when available), counselling and psychological support • Inform supervisor, for contact tracing and follow-up of family, friends, co-workers and other patients, who may have been exposed to the disease through close contact with the infected HCW/staff. 29. Managing Blood/ Body fluid Exposure • Persons including HCWs with percutaneous or muco-cutaneous exposure to blood, body fluids, secretions, or excretions from a patient with suspected or confirmed infectious disease, should immediately and safely stop any current tasks, and leave the patient care area. 187 • Safely take off PPE according to the steps in the procedure, in the anteroom • Treat affected exposed area: ⁺ wash the affected skin surfaces or the percutaneous injury site with soap and water ⁺ Irrigate mucous membranes (e.g. conjunctiva) with copious amounts of water or an eyewash solution, and not with chlorine solutions or other disinfectants. • Immediately report the incident to the chief of unit, IPC focal point (following hospital exposure procedure) as soon as the HCF staff exist the isolation room/ unit. • Exposed persons should be medically evaluated for: ⁺ infectious disease (ID) (of isolated patient) ⁺ other potential exposures (e.g., HIV, HCV) if sharp/needle-stick injury • Exposed persons must receive follow-up care, including: ⁺ fever monitoring, twice daily ⁺ period of recording symptoms will depend on the ID ⁺ Counselling and psychological support • Immediate consultation with an expert in infectious diseases for any exposed person who develops fever, symptoms after exposure. • If fever appears and other symptoms, isolate HCF staff, and follow procedure for ID suspected until a negative diagnosis is confirmed. Or • People suspected of having infected should be cared for/isolated, and the same recommendations outlined in this document must be applied until a negative diagnosis is confirmed. • Conduct contact tracing and follow-up of family, friends, co-workers and other patients, who may have been exposed to Ebola virus through close contact with the infected HCW/ staff. Section 6B.2 Healthcare Waste Management Procedures (HCWMP) 1. While approximately 80% of the wastes generated in a HCF are general waste, the remaining 20% comprise wastes that contain harmful microorganisms which can infect hospital patients, HCFs staff and the general public, as well as sharp objects and hazardous substances that can result in injuries, poisoning and pollution. Categorization of healthcare wastes 2. Healthcare waste is broadly categorized into two main groups, namely medical wastes and general wastes. 1. General wastes or household waste • Any waste that are solid or semi-solids generated from HCFs that are non-toxic and non-hazardous and are not contaminated with medical wastes. These are the food wastes, paper, plastics, textiles, non-toxic metals, glass and garden wastes. • In the event that general wastes are contaminated or mixed with any medical wastes, the general wastes shall be classified as medical wastes and managed accordingly. 2. Medical wastes • Any waste which consists completely or partly of human or animal tissue, blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or 188 dressings, syringes, needles or other sharps instruments, … all wastes that are hazardous or can cause infection to any person coming into contact with it. • Any other wastes generated from healthcare activities which may be hazardous or toxic. • The categories of medical wastes are: 1) Infectious wastes 2) Pathological wastes 3) Sharps wastes 4) Pharmaceutical wastes 5) Genotoxic wastes 6) Chemical wastes 7) Wastes with high content of heavy metals 8) Pressurized containers 9) Radioactive wastes 3. Proper healthcare waste management includes (1) waste segregation, (2) collection and handling, (3) stock in a safe temporary storage, (4) safe treatment and disposal. 1. Organize waste segregation: 4. All HCFs shall organize waste segregation at sources. Each type of waste should be contained in designated, color coded and labelled bags and containers. Below lists the guidance provided in the ESMF, however after discussion with PCO and DHHP, the MOH regulations related to health care waste management and the three-bin system with 3 color codes of bags will be applied and appropriate bins will be provided. These are: • Black bag: general waste or household waste • yellow bag: infectious waste, main part of the medical waste • red bag: other toxic and/or hazardous medical wastes. 2. Handling • Staff should handle medical waste as little as possible before storage and disposal. The more waste is handled, the greater the chance for accidents. • Special care must be taken when handling used needles and other sharps, which pose the greatest risk of accidental injury and infection. 5. Emptying waste containers 189 • Waste containers that are too full also present greater opportunities for accidents. Waste should be removed from operating theatres, procedure rooms, and sluice rooms before the containers become completely full. At the very least, these containers should be emptied once a day. Dispose of sharps containers when they are 3/4 full. (When sharps-disposal containers become too full, people may push sharps into the container, causing injury.) • Staff should wear utility gloves, heavy duty apron and boots when collecting waste. • Do not collect medical waste from patient-care areas by emptying it into open carts or wheelbarrows, as this may lead to spills and contamination of the surroundings, may encourage scavenging of waste, and may increase the risk of injury to staff, patients, and visitors. • Handle medical waste as little as possible. • Never put your hands into a container that holds medical waste. 3. Stock in a safe temporary storage 6. Following segregation, medical wastes should be placed in a designated, safe (locked) and temporary storage at HCFs. Different health care waste should be streamed separately in standard storage equipment. Storage time of infectious waste should not exceed 48 hours. Anatomical waste should be buried or disposed daily. 7. The central storage area must be: • Located separately from the general waste storage areas. • Should be clearly identifiable. • Away from food preparation, public access and egress route. • Arranged to store waste for landfill and waste for incineration waste separately. • Well ventilated and well lit. • Located on well drained, impervious hard-standing. • Provided facilities for washing down and disinfection. 4. Treatment and disposal of medical waste 8. General wastes can be removed to the regular community waste-disposal (land field). Infectious waste can be treated by the following methods: • Incineration. Two-chambered incinerators with proper temperature, required chimney heights should be used. The temperature must be at least of 800’C to ensure minimal emission of toxic gases at the primary chamber. Appropriate location and high chimney (higher than nearby roofs) are required. Pressured gas containers, radioactive wastes, radiographic wastes, halogenated plastics like PVC, mercury, cadmium and ampoules of heavy metals should never be incinerated. Lao PDR, there is one two-chambered incinerators for general and medical waste treatment being operated at KM32 landfill site in Vientiane. Health centers and district hospitals are recommended to transport sharp waste to these incinerators for treatment. • Single-chamber, drum and brick incinerators cannot meet the best available technology requirements of the Stockholm Convention on Persistent Organic Pollutants, of which Lao PDR is signatory. Emissions of toxic and persistent organic pollutants (dioxin, furans, etc.) from these small-scale incinerators may result in human exposure at levels associated with adverse health risks. The project 190 will not finance new small-scale onsite incinerator. If existing on-site incinerators are used, mitigation measures will be taken to control emissions to air in line with WBG EHS for healthcare facilities and WHO’s guidelines for safe management of waste generated from healthcare activities. • The good practices as follow: ⁺ Waste reduction and segregation to minimize quantities of waste to be incinerated; ⁺ Siting incinerators away from patient wards, residential areas or where food is grown; ⁺ A clearly described method of operation to achieve the desired combustion conditions and emissions; for example, appropriate start-up and cool-down procedures, achievement and maintenance of a minimum temperature before waste is burned, use of appropriate loading/charging rates (both fuel and waste) to maintain appropriate temperatures, proper disposal of ash and equipment to safeguard workers; ⁺ Periodic maintenance to replace or repair defective components; ⁺ Improved training for operators and improved management including the availability of an operating and maintenance manual, visible management oversight, and regular maintenance schedules. • Autoclave. Autoclave used to decontaminate infectious waste is required for laboratory (Level BS2+ and BSL3). They are available at the central laboratory and some provincial/district laboratories and hospitals in Lao PDR. All laboratory equipment, materials and fluids must be decontaminated in the autoclave, before being discharged out of the laboratory. • Sharp pit and Placenta pit: Placenta and small anatomical waste should be disposed to placenta pit and sharp waste should be transported and disposed by the high temperature incinerator. • Secured landfill. This is the minimal approach to sharp waste disposal, which should be used only in remote and underdeveloped areas. Even in difficult circumstance, the health facility should establish the following basic principles: ⁺ Locates the burial site away from the groundwater supply sources ⁺ Restrict access to the disposal site by unauthorized persons ⁺ Line the burial site with a material of low permeability, such as clay, dung and river silt, if available, to prevent pollution of shallow groundwater and nearby wells. ⁺ Burn sharp waste by incineration and infectious waste shall be disinfection by autoclaving before dispose at the landfill. ⁺ Each layer of waste should be covered by a layer of soil to prevent odors, rodents and insects. 5. Waste water collection and treatment a. Overall requirements 191 9. Health and environmental workers should always wear heavy utility gloves and shoes when handling or transporting liquid medical waste of any kind. When carrying or disposing of liquid medical waste, they should be careful to avoid splashing the waste on yourself, others, or on the floor and other surfaces. 10. Carefully pour liquid waste down a sink, drain, flushable toilet, or latrine. If this is not possible, bury it in a pit along with solid medical waste. Moderate quantities of mild liquid or semi-liquid pharmaceuticals such as solutions containing vitamins, cough syrups, intravenous solutions, eye drops (but not antibiotics or cytotoxic drugs), may be diluted in a large flow of water and discharged into municipal sewers. Pharmaceutical wastes shall not be disposed of into slow-moving or stagnant water. Pharmaceutical wastes shall not be disposed of into slow- moving or stagnant water. The HCF shall contact with a reliable waste management company for safe disposal instead 11. All facilities should have appropriate drainage. If the facility does not link to a treated municipal water drainage system, then all drainage should be treated locally. This includes appropriate septic and filtration systems. Highly infectious waste should be disinfected by proper disinfectants or autoclaved before they are disposed of either by incineration or non- incineration processes. Unless there is an adequate waste-water treatment plant, blood should be disinfected before discharged to a sewer. b. Management of faecal waste and wastewater in COVID-19 outbreak 12. There is no evidence that the COVID-19 virus has been transmitted via sewerage systems with or without wastewater treatment. Further, there is no evidence that sewage or wastewater treatment workers contracted the severe acute respiratory syndrome (SARS), which is caused by another type of coronavirus that caused a large outbreak of acute respiratory illness in 2003. As part of an integrated public health policy, wastewater carried in sewerage systems should be treated in well-designed and well-managed centralized wastewater treatment works. Each stage of treatment (as well as retention time and dilution) results in a further reduction of the potential risk. A waste stabilization pond (an oxidation pond or lagoon) is generally considered a practical and simple wastewater treatment technology particularly well suited to destroying pathogens, as relatively long retention times (20 days or longer) combined with sunlight, elevated pH levels, biological activity, and other factors serve to accelerate pathogen destruction. A final disinfection step may be considered if existing wastewater treatment plants are not optimized to remove viruses. Best practices for protecting the health of workers at sanitation treatment facilities should be followed. Workers should wear appropriate personal protective equipment (PPE), which includes protective outerwear, gloves, boots, goggles or a face shield, and a mask; they should perform hand hygiene frequently; and they should avoid touching eyes, nose, and mouth with unwashed hands. • Sanitation and plumbing 13. People with suspected or confirmed COVID-19 disease should be provided with their own flush toilet or latrine that has a door that closes to separate it from the patient’s room. Flush toilets should operate properly and have functioning drain traps. When possible, the toilet should be flushed with the lid down to prevent droplet splatter and aerosol clouds. If it is not possible to provide separate toilets, the toilet should be cleaned and disinfected at least twice daily by a trained cleaner wearing PPE (gown, gloves, boots, mask, and a face shield or 192 goggles). Further, and consistent with existing guidance, staff and health care workers should have toilet facilities that are separate from those used by all patients. 14. WHO recommends the use of standard, well-maintained plumbing, such as sealed bathroom drains, and backflow valves on sprayers and faucets to prevent aerosolized faecal matter from entering the plumbing or ventilation system, together with standard wastewater treatment.21 Faulty plumbing and a poorly designed air ventilation system were implicated as contributing factors to the spread of the aerosolized SARS coronavirus in a high-rise apartment building in Hong Kong in 2003.22 Similar concerns have been raised about the spread of the COVID-19 virus from faulty toilets in high-rise apartment buildings.23 If health care facilities are connected to sewers, a risk assessment should be conducted to confirm that wastewater is contained within the system (that is, the system does not leak) before its arrival at a functioning treatment or disposal site, or both. Risks pertaining to the adequacy of the collection system or to treatment and disposal methods should be assessed following a safety planning approach,24 with critical control points prioritized for mitigation. • Toilets and the handling of faeces 15. It is critical to conduct hand hygiene when there is suspected or direct contact with faeces (if hands are dirty, then soap and water are preferred to the use of an alcohol-based hand rub). If the patient is unable to use a latrine, excreta should be collected in either a diaper or a clean bedpan and immediately and carefully disposed of into a separate toilet or latrine used only by suspected or confirmed cases of COVID-19. In all health care settings, including those with suspected or confirmed COVID-19 cases, faeces must be treated as a biohazard and handled as little as possible. Anyone handling faeces should follow WHO contact and droplet precautions and use PPE to prevent exposure, including long-sleeved gowns, gloves, boots, masks, and goggles or a face shield. If diapers are used, they should be disposed of as infectious waste as they would be in all situations. Workers should be properly trained in how to put on, use, and remove PPE so that these protective barriers are not breached.25 If PPE is not available or the supply is limited, hand hygiene should be regularly practiced, and workers should keep at least 1 m distance from any suspected or confirmed cases. 16. If a bedpan is used, after disposing of excreta from it, the bedpan should be cleaned with a neutral detergent and water, disinfected with a 0.5% chlorine solution, and then rinsed with clean water; the rinse water should be disposed of in a drain or a toilet or latrine. Other effective disinfectants include commercially available quaternary ammonium compounds, such as cetylpyridinium chloride, used according to manufacturer’s instructions, and peracetic or peroxyacetic acid at concentrations of 500−2000 mg/L. 17. Chlorine is ineffective for disinfecting media containing large amounts of solid and dissolved organic matter. Therefore, there is limited benefit to adding chlorine solution to fresh excreta and it is possible that this may introduce risks associated with splashing. • Safely disposing of greywater or water from washing PPE, surfaces and floors. 18. Current WHO recommendations are to clean utility gloves or heavy duty, reusable plastic aprons with soap and water and then decontaminate them with 0.5% sodium hypochlorite solution after each use. Single-use gloves (nitrile or latex) and gowns should be discarded after each use and not reused; hand hygiene should be performed after PPE is removed. If greywater includes disinfectant used in prior cleaning, it does not need to be chlorinated or treated again. However, it is important that such water is disposed of in drains 193 connected to a septic system or sewer or in a soakaway pit. If greywater is disposed of in a soakaway pit, the pit should be fenced off within the health facility grounds to prevent tampering and to avoid possible exposure in the case of overflow. 194 Attachment 3. WHO Recommendations on HCWMP in Lao PDR 1. During 2020-2021 (as part of the Safe, Clean, and Green Hospital Initiative17), WHO team in Lao PDR conducted a quick assessment of existing waste management from some selected healthcare facilities (HCFs) an provide recommendations on the planning and logistic systems for health care waste management in district and provincial/medium sized-regional and central hospitals (up to 150 beds) in Lao PDR. Key recommendations are highlighted below. 2. Equipment and Infrastructure requirements for HCWs at central, regional (medium size), provincial and district hospitals •The successful management of a healthcare waste management system in a hospital will require certain equipment and infrastructure. In the following, the minimum requirements for equipment and infrastructure for a healthcare waste system for district hospital and higher is described below with photos. Consumables such as bags, sharp containers, etc. are not included. The list is based on a code system. Technical description and specification of the equipment can be found in the table below. • Internal equipment: At ward level, a set of infectious waste bins as well as collection bin for interim storage. • Personal Protection Equipment: Safety goggles, working gloves for chemicals, working gloves for logistic activities, overall, etc. • Single use items: Different bags for different purposes, safety boxes, sharps container, disinfectants, etc. • Waste function area/room: The function area/room should have some equipment (autoclave, weigh/scale) available for storage and treatment of hazardous waste and reporting recording. 3. Lists of basic supply and equipment for a) Health Center, b) PHs DHs, c) Central and regional hospitals Table 1. Logistic estimation for health centers/small hospital Minimum Equipment – small hospital and health center For a detailed description of the equipment, please see the technical specifications Unit Code Item cost Amount Total budget PPE-01 Personal Protection Equipment PPE-01-01 Safety goggles 3 PPE-01-02 Working gloves - chemicals 3 PPE-01-04 Working gloves - logistic 5 PPE-01-05 Working overall 2 PPE-01-06 Safety boots 2 PPE-01-09 Working gloves - Heat resistant 2 LOG-02 Internal equipment LOG-02-01 Infectious Waste Bin - Small 3 17 WHO unpublish report (dated 11 Sept 202o and revised in February 2021) 195 LOG-02-03 General Waste Bin - small 4 LOG-02-09 Outdoor - waste bin 2 LOG-03 Equipment in waste funcional room LOG-03-01 Wheelie-Bin 240 (General Wa.) 2 LOG-03-13 Ground scale 1 LOG-03-15 Water hose/pressure pump for cleaning bins and equipment 1 LOG-03-16 Hand washing station 1 5000 Total cost Estimated cost USD 4. Infrastructure requirements for health center/community hospital/small hospital with 1-10 beds: ▪ Waste storage place, small-scale ▪ Sharp pit - basic requirement for all HCFs (standard is available, can use for 5 year) ▪ Placenta pit, if required (basic standard is available, it can be used for 5 year) 5. Estimated cost 2000-3000US per sharp pit or /placenta pit construction (using WHO standard design and follows same size and lifetime is 5 years) Table 2. Logistic Estimation for Provincial and District Hospitals Minimum Equipment – Provincial and DHs For a detailed description of the equipment, please see the technical specifications Total Code Item Unit cost Amount budget PPE-01 Personal Protection Equipment PPE-01-01 Safety goggles 10 PPE-01-02 Working gloves - chemicals 10 PPE-01-03 Anti-Needlestick Gloves 2 PPE-01-04 Working gloves – logistic 20 PPE-01-05 Working overall 5 PPE-01-06 Safety boots 5 PPE-01-09 Working gloves - Heat resistant 2 LOG-02 Internal equipment LOG-02-01 Infectious Waste Bin - Small 60 LOG-02-02 Infectious Waste Bin - Large 4 LOG-02-03 General Waste Bin - small 30 LOG-02-04 Outdoor - waste bin 10 LOG-02-05 Pathological waste bin – small and medium size 10 LOG-02-06 Sharp box or sharp container 12 daily LOG-02-07 Needle Cutter 12 LOG-03 Log. Equip. waste func.area LOG-03-01 Wheelie-Bin 240 (General Wa.) 20 20 LOG-03-03 Collection Bin - Infect. Waste 20 20 LOG-03-04 Bin trolley (infect. Waste) 2 2 LOG-03-09 Transp. Containter Lamps 1 1 196 LOG-03-10 Cont. for solid Haz. Waste 1 1 LOG-03-13 Ground scale 1 1 LOG-03-14 Pressue Sprayer - Disinfect 1 1 LOG-03-15 Water hose 1 1 LOG-04 Equipment Chemical Storage LOG-04-05 60 l Drum for storage of batteries 3 3 LOG-04-06 30 l jerry can 6 6 LOG-04-01 Genotoxic waste collection buckets (Red) 10 2 20 TRE-01 Waste treatment equipment TRE-01-06 Autoclave-VSV-45-85L 10200 1 1 TRE-01-10 Start-up-Autoclve+Spare+Moni 1000 1 1 TRE-01-11 Chemical test (color test) for autoclave 1000 500 Manpower 1 transporter 1 autoclave operator USD/month Estimated cost (an average) 16,000 - Excluding 20,000 manpower 6. Requirements for central hospitals Note: Quantities are designed for central and regional hospital with 150 beds. In case of larger facility, the position LOG-02 has to be adjusted. Table 3. Basic logistics and equipment for central and regional hospitals, medium-sized (up to 150 beds) Minimum Equipment – central, regional hospital For a detailed description of the equipment, please see the technical specifications Unit Code Item cost Amount Total budget PPE-01 Personal Protection Equipment PPE-01-01 Safety goggles 10 PPE-01-02 Working gloves - chemicals 10 PPE-01-03 Anti-Needlestick Gloves 2 PPE-01-04 Working gloves – logistic 20 PPE-01-05 Working overall 5 PPE-01-06 Safety boots 5 PPE-01-09 Working gloves - Heat resistant 2 LOG-02 Internal equipment LOG-02-01 Infectious Waste Bin - Small 60 LOG-02-03 General Waste Bin - small 30 LOG-02-09 Outdoor - waste bin 10 LOG-03 Log. Equip. waste func.area LOG-03-01 Wheelie-Bin 240 (General Wa.) 20 LOG-03-03 Collection Bin - Infect. Waste 20 LOG-03-04 Bin trolley (infect. Waste) 2 LOG-03-09 Transp. Containter Lamps 1 LOG-03-10 Cont. for solid Haz. Waste 1 197 LOG-03-13 Ground scale 1 LOG-03-14 Pressue Sprayer - Disinfect 1 LOG-03-15 Water hose 1 LOG-04 Equipment Chemical Storage LOG-04-05 60 l Drum for storage of batteries 3 LOG-04-06 30 l jerry can 6 TRE-01 Waste treatment equipment TRE-01-06 Autoclave-VSV-100-150l 1 TRE-01-10 Start-up-Autoclve+Spare+Moni 1 TRE-01-11 Chemical test (color test) for autoclave 20,000- Estimated budget 25,000 7. Infrastructure requirements for central and provincial hospitals: ▪ Waste storage place, medium ▪ Placenta pit, required (depends on culture) Appendix 1. List of internal equipment and logistics with photos defined based on the minimum requirements for safe waste management Waste management Key requirements and logistics Waste segregation Basic three bin system for general/domestic waste (black color), waste for infectious and sharp waste (yellow color) is recommended. Infectious and sharp waste collection • Sharps and disinfected highly infectious waste shall be collected together with the infectious waste. • each bin in wards should be emptied every day and cleaned and disinfected regularly. • Pharmaceutical waste shall be collected at the nursing station and shall be brought back to the pharmacy. At the pharmacy the pharmaceuticals shall be sorted by fertilizing with autoclave then send them to landfill for further disposal. Intermediate storage • Infectious and sharp waste can be safely stored in intermediate storage area 198 • Hazardous chemical waste shall be collected at the laboratory, radiology, pathology and other places and shall be brought to the interim hazardous waste disposal place for interim storage. Internal transport • Transport infectious, and sharp waste from intermediate storage area to central storage • Separate transport of hazardous and non- hazardous waste (yellow - black) • Transport equipment should be dedicated for waste transportation only Domestic/general waste storage area • Domestic/general waste storage areas • General waste is picked by UDA (VUDA in Champasack, Sekong and Attapeu) every 24 or 48 hours. Central storage for hazardous waste and waste function • Central waste function area area is recommended for central, provincial and district hospitals. • It has rooms for infectious and sharp waste treatment (autoclave), area to receive hazardous waste and storage for treated and recyclable waste Treated waste is transported by External transport and safe disposal at landfill of the UDA from hospital to landfill of towns: the provincial or district towns. (Intersectoral coordination and support of the district governor office) 199 Anatomical waste disposal 8. Main function area/room is to support maintenance of the logistic assets (cleaning and disinfection of waste bins) and receive hazardous wastes. There is small scale autoclave must be available for infectious and sharp waste treatment (See Figure 1). The following main areas will be needed for HWC function area: A) Non-infectious/general waste storage facility (waste storage tank, container e.g.) B) Hazardous waste storage room with storage and treatment area for infectious waste C) Multipurpose storage area for waste recycling D) Cleaning and maintenance area for waste logistic equipment 9. Estimated budget for construction waste operation room 2000-5000US, based on current example in Southern provincial hospital (WHO Safe Clean Green HCF project, 2020- 21), if a hospital uses own labour cost. 200 Appendix 2: Labelling requirements Labelled Wheelie Bin Labelled Container Labelled Sharps Container on the right hand Photo 1: labelling example and types of bins/containers Requirement for bins and containers Waste Colour and Collection Type of container categories markings frequency Leak-proof strong plastic bag placed When three-quarters in a container (bags for highly filled or at least Infectious waste infectious waste should be capable once a day. of being autoclaved). Puncture-proof container. When filled to the Sharp waste line or three- quarters filled. Leak-proof strong plastic bag placed When three-quarters Pathological in a container. filled or at least waste once a day. Chemical and Plastic bag or rigid container. On demand. pharmaceutical waste Lead box. On demand. Radioactive waste Black or Plastic bag inside a container or When three-quarters General health- container which is disinfected after filled or at least grey care waste use. once a day. coloured bag 201 Annex 7: Indicative forms for GRM and accident reporting 7A. Sample Form of Grievance Redress Mechanism (GRM) Monitoring Sample Form of Grievance Redress Mechanism (GRM) Monitoring Village:………………………………; District:…………………… ……………; Provinces:…………………………………………………. Ethnic Status of action Grievance Group taken applied by Date of Grievance Solved Action Remarks/ Brief Description/ and contact Date of No grievance received or taken nature of grievance detail or action Explanation received by what by code (not completed mandatory) action or taken taken 202 7B. Accident Reporting Procedure and Form (sample) Serous Case: Accident Minor Case Occurred: Do not move the injured person (IP) Accident Reporter/ Worker who are not injured: 1. Immediately calls Provincial Rescue/ Nearest Hospital: • Rescue Number: xxx • Nearest Hospital: xxx Accident Reporter/ Worker who are not injured: 2. Take photos or record video of the accident for reporting 3. Calls contractor site engineer (CSE): active number 4. Send the IP to nearest hospital by Rescue/hospital car Contractor site engineer (CSE): 5. Immediately heads to the accident site or hospital where the IP transferred to 6. Inspect and take photos for reporting 7. Calls site supervision (SS)-name and active number of SS HCF owner, PHO/DHO, and site supervision (DSS): 8. Immediately heads to the accident site or hospital where the IP transferred to 9. Inspect, take photos and fill the accident report form 10. Report to PCO and send photos of accident in the WhatsApp group on the day of accident occurred. PCO/DHR: 11. Inform and report to WB within 24 hours 12. Follow up the situation of IP Filing Accident Report 13. Keep a copy of Accident Report at contractor office, PCO, DHR, WB 14. Include the accident report in the monthly and quarterly safeguard monitoring report 203 ACCIDENT REPORT Date of the Accident: Time: Location: Type of Accident: Detailed Description of the Accident: Responses / Corrective Actions Taken: Possible Causes(s) of the Accident: Suggested Preventive Measures: Submitted by: Position: Signature: Date: Reviewed by: ____________________ Date : __________ 204 7C: ESMP Monitoring Form (Sample) Lao People’s Democratic Republic Peace Independence Democracy Unity Prosperity ***** Lao PDR COVID-19 Response Project Credit No. IDA 6606-LA Project ID: No. P173817 Monthly/Quarterly Implementation Report on Environmental and Social Measures Date:……/…../…….. Prepared by:……………………. 205 I. Brief progress of the project ……….Construction company was signed contract on……………which the construction started on ............... and will be completed on .............................. To date, the progress of the construction work has been completed ........%, including the following important works: 1. .................................. 2. .................................. Some pictures (when taking pictures, pay attention to the trash must be orderly, workers must wear personal protective equipment) II. Implementation of environmental and social measures 2.1. Well-implemented environmental and social measures At the time of this report, the environmental and social measures that the Company has implemented well are summarized in the table below. The image is in appendix 1. Table 1 Summarize measures that are well implemented Topic Description 1. Install safety warning signs at all risk points, Figure 1-5 in Appendix 1 2. 2.2. Environmental and social measures to be taken into account At the time of this report, the environmental and social measures that the Company has not yet well implemented are summarized in the table below. The image is in appendix Table 2 Summarize the measures that have not yet been implemented well Measure are not yet well implemented Solution Completion date 1. Do not install safety warning signs at all 1. Resolved/ 1. risk points unresolved 2. XXXX 2. XXXX 3. XXXXX 3. XXXXX 1. 1. 2. 206 III. Reporting on accident 1. During the period of this report, no accidents / accidents occurred ........... times. Explain the accident and attach an accident report. Appendix 3. IV. Complaint Monitoring At the time of this report, there have been a number of complaints ............... cases. Of these, .................... cases have been resolved and .................... cases have not been resolved. Details are summarized in the table below. Details are attached in Attachment 6: Table 3 Redress Complaint No. Complaint Description Be resolved Still Remarks unresolved V. Labor management and local employment The total number of staff, technicians and workers of the company who work for this project is .......... people (……. are women). The number of workers from the local area is…….. (……. are women). The list of staff, technicians and workers is in Attachment 7 The number of workers staying in the camps is ........ people, the company has provided the following facilities: Table 4 Camp Facilities Camp Facility Amount Remarks Dormitory for for 30 people 8x8 m Roofing with zinc or grass, paving by wood and zinc wall, with mosquito net Where to cook and where to eat Shared kitchen Toilet and bathroom 2 toilets, 2 bathrooms Electricity From public electricity Drinking water From the drinking water factory Water used Water supply Food Market Waste bin In the kitchen and in front of the camp First aid kit Medicine for fever, cold, medicine for stomach pain, headache and so on PPE Fire extinguisher, hat, reflective jacket, shoes Information board Write a work plan and rules Basic salary Other Take a photo of everything listed in the table above 207 VI. Difficulty/challeng and proposed suggestions Table 5 Difficulty/Challenge with Propose solution Difficulty/Challenge Proposed solution VII. Appendix (if any) Appendix 1: Picture of a well-implemented measure Appendix 2: Measures that are not implemented well Appendix 3: Accident reports Appendix 4: Complaint Record Form Appendix 5: Complaint Record Form Appendix 6 List of staff, technicians and workers working at the site Appendix 6 List of staff, technicians and workers working at the site No. Name and Position Tel From Status Emergency Stay at Family (Single / contact camp name Married) number 208 Annex 8: Summary of the SS-ESMP Consultation This annex presents a brief summary of the consultation results obtained from consulting with various groups of stakeholders to solicit their feedback on the draft SS- ESMP for the new HCF for COVID-19 treatment located in Sekong Provincial Hospital. Due to COVID-19 restriction on social gathering, face-to-face meetings could not be organized. In an effort to conduct the consultation, virtual meetings were organized with various groups of stakeholders, including: 1. Provincial and district health officers (from concerned units), 2. District DONRE, LFND, LWU, 3. Patient and villager representatives (males and females) and 4. Villages authority. The consultation results are briefly summarized below and most of them have been incorporated into this SS-ESMP for the HCF in Sekong Provincial Hospital, Sekong Province. Participants include: Stakeholder group Number of participants Total Notes participants Male Female Ethnicity 1. Provincial and district 8 5 Lao 13 health officers 2. District DONRE, 1 2 Lao 3 LFND, LWU, 3. Patient and village 3 4 Lao 7 representatives (include people with disability and vulnerable group) 4. Villages authority 2 Lao 2 Total 14 11 25 Key information provided to consulted stakeholders include: • Overview of the new HCF (purpose, nature, scope, activities, etc.); • Risks and impacts and proposed mitigation measures (during construction phase of the new HCF); • Risks and impacts and proposed mitigation measures (during operations phase of the new HCF); • Grievance Redress Mechanism (GRM); • Others. After the presentation, guiding questions were asked to facilitate the discussion among consulted stakeholders. These key questions are aligned with the structure of the presentation above, and are as follows: 1. What are your opinions regarding the Covid-19 treatment facility to be constructed in the existing local hospital under this project? 2. From the presented information regarding the potential environmental and social risks and impacts during construction and operation phases, do you have any feedback (concerns, questions, suggestions)? 209 3. Do you think the proposed mitigation measures (as presented) for environmental and social risks and impacts are sufficient and appropriate – from your perspective, during construction phase? If not, what other measures do you think should be taken? 4. Do you have any concerns about this new treatment facility, and/or any suggestions on improving the services of the new HCF facility once completed and put into operation? Key feedback from consulted participants: • For the construction of the Covid-19 treatment facility, it is a good project and we agree with the construction because it will bring benefit for Sekong Province, especially Covid- 19 patient to get the proper treatment and to reduce the risk of death from such disease. • The construction of the new HCF will generate noise, air pollution and other impacts due to operations of machinery during demolish and construction. Therefore, relevant authorities and stakeholders must be highly attentive to these risks and impacts, and be responsible for avoiding/minimizing these risks and impacts. • If the project still have budget, we would like to propose to have a proper hole or landfill for disposal glass tubes, waste glass, medicine tubes. This is due to the past experience showed that Sekong Provincial Hospital had problem with this issue, which has not yet been solved. • Project owner’s management measures are considered to be complete. However, construction company (Contractors) should be aware of these risks that will arise during construction should manage these risks very effectively. • Where possible, use local labor is encouraged to control and reduce the risk of outbreaks of Covid-19 from other outsource and to create jobs for the surrounding people as well as within the province. • Once the project is completed, training on risk prevention of Covid-19 should be provided to the cleaning staff of the Sekong Provincial Hospital to have more self-protection. Annexes: • Annex 8.1. Consultation Tools used for consultation • Annex 8.2. List of participants • Annex 8.3. Some Photos of Consultations • Annex 8.4. Minutes of Meeting 210 • Annex 8.1. Consultation Tools used for consultation 211 212 213 • Annex 8.2. List of participants 214 215 • Annex 8.3. Some Photos of Consultations 216 • Annex 8.4. Minutes of Meeting (The content of this Minutes has been summarized in English in the beginning part of Annex 8). 217 218 Annex 9: Lao PDR National Environmental Standards (Revised 2017) Lao People’s Democratic Republic Peace Independence Democracy Unity Prosperity Ministry of Natural Resources and Environment Agreement On National Environmental Standards (Decree Promulgated on Approved National Environmental Standards 81/GOV, Effective 21 February 2017) Department of Pollution Control 2017 All Rights Reserved 219 Lao People’s Democratic Republic Peace Independence Democracy Unity Prosperity Government No 81 /GOV Capital City of Vientiane, dated 21.02.2017 Decree Promulgated on Approved National Environmental Standards 1. With reference to the Law on Government of the Lao P.D.R. No 69/NA, dated 15 December 2015, 2. The law on Making Legislation No 19/NA, dated 12 July 2012. 3. The Environmental Protection Law No 29/NA, dated 18 December 2012, 4. And the report of the Ministry of Natural Resources and nvironment 0485/MONRE, dated 07 February 2017 The Government issues the following Decree: Article 01: Approved and Promulgated “National Environmental Standards” Article 02: The Ministry of Natural Resources and the Environment shall collaborate with other Ministries, equivalent organizations, and local authorities to review and implement the National Environment Standards effectively. Article 03: Ministries and equivalent organizations, the Vientiane municipality, provinces, and relevant sectors shall acknowledge, cooperate, and implement this decree effectively. Article 04: This decree enters into force on the day it is signed. Governmental Representative of Lao PDR. Prime Minister Thongloun Sisoulith 220 Content Table Page Chapter 1 General Provision Article 1 Objective 1 Article 2 National Environment Standards 1 Article 3 Definition 1 Article 4 Scope of Application 2 Chapter 2 Air Standards 3 Article 5 General Air Quality Standards 3 Article 6 Air Pollution Emission Control Standards 4 Article7 Air Pollution Emission Control Standards for Vehicle 8 Chapter 3 Soil Standards 10 Article 8 Soil Quality Standards 10 Chapter 4 Water Quality 15 Article 9 General Water Quality Standards 15 Article 10 Surface Water Quality Standards 15 Article 11 Underground Water Quality Standards 18 Article 12 Drinking Water Quality Standards 22 Article 13 Drinking Water Quality Standards in covered container 24 Article 14 Water Pollution Control Standards 26 Chapter 5 Noise and Vibration Standards 34 Article 15 General Noise Standards 34 Article 16 Vibration Control Standards 35 Chapter 6 Final Provision 38 Article 17 Implementation 38 Article 18 Effective 38 Attachment 221 Tables of National Environmental Standards Page Table 5: General Air Quality Standards 3 Table 6: Air Pollution Control Standard for General Industry 4 Table 6.1: Air Pollution Control Standards for Power Plant Thermal Energy 5 Table 6.2: Air Pollution Control Standards for Annealing Factory 6 Table 6.3: Air Pollution Control Standards for Cement Factory 6 Table 6.4: Air Pollution Control Standard for Crushing Stone Business 6 Table 6.5: Air Pollution Control Standard for General Waste Furnace 6 Table 6.6: Air Pollution Control Standards for Infected Wastes from Hospital 7 Table 7.1: Air Pollution Control Standards for new Vehicles 8 Table 7.2 Air Pollution Control Standards for operating Vehicles 9 Table 8.1: Soil Quality Standards for Residential and Agriculture 10 Table 8.2: Solid Pollution Control Standard for other utilization purpose 12 Table 10: Classification of Surface Water Quality 15 Table 11: General Underground Water Quality 19 Table 11.1: Underground Water Standard for Consumption 21 Table 12: Drinking Water Quality Standard 22 Table 13: Drinking Water Quality Standards in covered Container 24 Table 14: Water Pollution Control Standards for General Factories 26 Table 14.1: Category and size of Building to be controlled for Water Pollution 28 Emission Table 14.2: Water Pollution Control Standards for Building 29 Table 14.3: Water Pollution Control Standards for Housing Estate 30 Table 14.4: Water Pollution Control Standards for Toilet 30 Table 14.5: Water Pollution Control Standards for Public Canal 31 Table 14.6: Water Pollution Control Standards for Pig Farm 32 Table 14.7: Water Pollution Control Standards for Car Wash and Gas Station 33 Table 15: General Noise Standards 34 Table 15.1: Noise Control Standards 34 Table 15.2: Noise Control for Machine and Vehicle 34 Table 15.3: Noise Pollution for Mining Activities and Stone Explosion 35 Table 16: Vibration Control Standards for Mining Activities and Stone Explosion 35 Table 16.1: How to measure the vibration 37 222 Agreement on National Environmental Standard Based on the Environmental Protection Law No.29/NA, dated: 10 December 2012. Article 29 and Article 32. Minister agreed: Chapter 1 General Provisions Article 1: Objective This agreement defines indicator and pollutant concentration in the National Environmental Standards as the science basic for environmental monitoring and pollution control on air, solid and water including disturbance things that effected to life, people’s health, animal and environment. Article 2: National Environmental Standards National Environmental Standards defines chemical value concentration indicator and a waste contaminated in the air, soil and water including disturbance that covered general environmental standards and pollution control standards which is the technical science tools and to be the reference as one standard for all relevant for protection and pollution control works. Article 3: Definition Definition using in this agreement has defined below: Environmental Standards means concentration value of the indicator in an environment of quality standard for air, soil and water including disturbance thing which is defined to be total standards for general promotion and environment protection; Pollution Control Standards means concentration value of the indicator for controlling of chemical contamination volume and contamination from original sources discharged into air, solid and water environment including disturbance; C) Concentration means chemical volume contaminated in the air, soil, water including disturbance thing which is the numeral and figure out based on the parameter; D) Parameter means examination defines factors of each pollutant that needs to follow up, monitoring and control in order to measure concentration based on National Environmental Standards defined with chemical alphabet symbols; E) Indicator means standards value defines concentration of indicator in the National Environmental Standards which is scientific figures. 223 For the definition of chemical mentioned is explained in the annex of this agreement. Article 4. Scope of Application This agreement is apply to any relevant person, entity and organization in order to implement pollution control discharged to environment in Lao PDR. Chapter 2 Air Standards Article 5 General Air Quality Standards Air quality standards in general are signified as values indicating concentrations of chemicals and additives or contaminants in the air, which indicate general standards for safety controls, as follows: Table 5: Air Quality Standards in General Measurement Symbol Average Value Unit standards not to exceed 1 hour 30 ppm CO Carbon monoxide 8 hours 9 ppm 1 hour 0.11 ppm NO2 Nitrogen dioxide 1 year 0.02 ppm 1 hour 0.13 ppm SO2 Sulfur dioxide 24 hours 0.05 ppm TSP 24 hours 0.33 mg/m3 Total Suspended Particulates 1 year 0.10 mg/m3 24 hours 0.12 mg/m3 PM-10 Particulate Matter 10 3 1 year 0.05 mg/m 224 24 hours 0.05 mg/m3 PM - 2.5 Particulate Matter 2.5 1 year 0.015 mg/m3 O3 1 hour 0.20 mg/m3 Article 6 Air pollution Emission control standards Air pollution control standards are indicated as the highest allowable concentrations of chemicals and additives released into the air for each activity, size, type of pollution source, and pollution substance from source of origin. These must be in line with pollution control standards for substances released into the air as stated below: Table 6: Air pollution control standards for general industry factories Air pollution control Source of standard not to exceed Measurement Symbol Unit Air pollution No Fuel combustion combustion TSP Burner and incinerator using heat source as Total Suspended follows: Particulate Fuel oil 240 mg/m3 Coal 320 mg/m3 Biomass Undefined 320 mg/m3 Other fuels 320 mg/m3 Smelting procedure, squeeze, metal 300 240 mg/m3 pulling (steel and aluminum) General 400 320 mg/m3 production SO2 Burner and incinerator using heat source as Sulfur dioxide follows: Fuel oil 950 ppm Coal Undefined 700 ppm 225 Biomass 60 ppm Other fuels 60 ppm General 500 ppm Undefined production NOx as Burners or incinerators using heat source as follows: Nitrogen dioxide NO2 Fuel oil 200 ppm Coal 400 ppm Not Biomass 200 ppm indicated General 200 ppm production General ppm Carbon monoxide CO 870 690 production Air pollution standard not to exceed Unit source Non- Fuel Indicator Symbol Air pollution combustible combustion value fuel H 2S General 140 110 mg/m3 Hydrogen sulfide production HCl General 200 160 mg/m3 Hydrogen chloride production H2SO4 Sulfuric acid 100 mg/m3 Sulfuric acid production C8H10 General 870 Not mg/m3 Xylene production indicated Cresol C 7H 8 O General 5 mg/m3 226 production Sn General 20 16 mg/m3 Tin production As General 20 16 mg/m3 Arsenic production Cu General 30 24 mg/m3 Copper production Pb General 30 24 mg/m3 Lead production Cl General 30 24 mg/m3 Chlorine production Hg General 3 2.4 mg/m3 Mercury production Table 6.1: Air pollution control standards for electric power factory Standard Unit Measurement Symbol Coal Oil Gas Sulfur dioxide Size of Factory > 500 MW 320 320 20 ppm Size of Factory 300 - 500 MW SO2 450 450 20 ppm Size of Factory < 300 MW 640 640 20 ppm NOx as NO2 350 180 120 ppm Nitrogen dioxide TSP 120 120 60 mg/m3 Total Suspended Particulates Table 6.2: Air pollution control standards for smelting metal factory. 227 Measurement Symbol Standard Unit TSP 120 mg/m3 Total Suspended Particulates SO2 180 ppm Sulfur dioxide NOx as NO2 120 ppm Nitrogen dioxide Table 6.3: Air pollution control standards for cement factory Standards Sulfur dioxide Nitrogen dioxide Pollution Source Total Suspended (SO2) (NOx as NO2) Particulate (TSP) ppm ppm mg/m3 General Cement Incinerator Not to exceed 120 Not to exceed 50 Incinerator for lime Not to exceed 120 Not to exceed 500 Not to exceed 500 Mortar Smelting pot, Not to exceed 120 Not to exceed 500 Cement mill and Coal mill Table 6.4: Air pollution control standards for stone mill factory Measurement Total Suspended Particulate Opacity (mg/m3) (%) With no particulate trapping Undefined 20 system With particulate trapping system 400 20 Table 6.5: Air pollution control standards for general waste incinerator Standards Measurement Symbol Size of Incinerator Unit 228 1 - 50 More tons/day than 50 tons/day TSP Total Suspended 400 120 mg/m3 Particulate SO2 30 30 ppm Sulfur dioxide NOx as NO2 250 180 ppm Nitrogen dioxide Opacity 20 10 % Opacity HCl 203 37 mg/m3 Hydrogen chloride Dioxin 30 30 ng/m3 Dioxins Table 6.6: Air pollution control standard of infected waste incinerator for health sectors Measurement Symbol Standard Unit SO2 30 ppm Sulfur dioxide NOx as NO2 180 ppm Nitrogen dioxide HCl 37 mg/m3 Hydrogen chloride HF 16 mg/m3 Hydrogen Fluoride Total Suspended TSP 120 mg/m3 Particulate Opacity Opacity 10 % 229 Hg 0.05 mg/m3 Mercury Cd 0.05 mg/m3 Cadmium Pb 0.5 mg/m3 Lead Remark: For Industry zones, or where many factories are in the same location, the standards will be specified. Article 7 Air pollution emission control standards for vehicles Air pollution emission control standards for vehicles are the highest concentrations of chemicals indicated, and the contamination released into the air environment from the usage of each type, type of engine and vehicles, as in the pollution control standards indicated as follows: CH C bH oy nd oo ib do en nc oa (( )) r xr O m C Table 7.1: Air pollution controlling standards for new vehicles. a r ParticulateMatter(PM) NitrogenOxide(NO Unit HC+NO Smoke x ) x Type of Vehicles Vehicles using gasoline Public bus 1 0.1 - 0.08 - - g/km Vehicles weighing 1 0.1 - 0.08 - - g/km less than 1305 kg Vehicles weighing 1.81 0.13 - 0.1 - - g/km 1305 to 1760 kg 230 Vehicles weighing 2.27 0.16 - 0.11 - - g/km over 1760 kg Vehicles using diesel Public bus 0.5 - 0.3 0.25 0.025 - g/km Vehicles weighing 0.5 - 0.3 0.25 0.025 - g/km less than 1305 kg Vehicles weighing 0.63 - 0.39 0.33 0.04 - g/km 1305 to 1760 kg Vehicles weighing 0.74 - 0.46 0.39 0.06 - g/km over 1760 kg Trucks which 1.5 0.46 - 3.5 0.02 0.5 g/kWh use diesel Table 7.2 Air pollution control standard for vehicles in use Type of Measurement Standard Measuring device Measuring method Vehicle 50% Filter paper system Measure while car is Opacity measuring parked with load and at Vehicles 45% system highest RPM 231 using diesel Black Smoke 40% Filter paper system Measure while car is Opacity measuring running and speed at 60% 35% system of highest RPM Vehicles Carbon 4.5% Non – Dispersive Measure while car is using monoxide Infrared Detection parked without load gasoline 600 mg/Km Hydrocarbon Carbon 4.5% Non-dispersive Measure while car is monoxide Infrared Detection parked without load 10000 Motorbike Hydrocarbon mg/Km Measure while car is Smoke Meter, Full parked without load and 30% Flow Opacity White Smoke speed 75% of highest System RPM Chapter 3 Soil Standards Article 8 Soil Quality Standards 232 Soil Quality Standards are indicated as highest concentrations of chemical contaminants and soil contamination which will not cause harm to the life or health of people, animals, or the environment through direct or indirect contact with the soil. Soil quality standards are specified below: 233 234 235 Not to exceed CCl4 mg/kg Carbon Tetrachloride 5.3 Not to exceed CH2 Cl-CH2 Cl mg/kg 1,2-Dichloroethane 7.6 Not to exceed CCl2=CH2 mg/kg 1,1-Dichloroethylene 1.2 Not to exceed C is - C2 H2 Cl2 mg/kg Cis-1,2-Dichloroethylene 150 Not to exceed Trans -C2 H2 Cl2 mg/kg Trans-1,2- Dichloroethylene 210 Not to exceed CH2 Cl2 mg/kg Dichloromethane 210 Not to exceed Ethylbenzene C6H5-C2H5 mg/kg 230 Not to exceed Styrene C6H5-CH =CH2 mg/kg 1,700 Continue table 8.2 Chemical Measurement Standard Unit Analysis method formula Not to exceed Cl2 C= CCl2 mg/kg Tetrachloroethylene 190 236 Not to exceed C6H5-CH3 mg/kg Toluene 520 Not to exceed Cl2 C=CHCl mg/kg Trichloroethylene 61 GC or GC/MS Cl3 C-CH3 Not to exceed mg/kg 1,1,1-Trichloroethane 1,400 Cl2CH-CH2Cl Not to exceed mg/kg 1,1, 2-Trichloroethane 19 o, m, p (CH3- Not to exceed mg/kg Xylene C6 H4 -CH3) 210 Heavy Metal ICP/AES or ICP/MS or AA/Furnace Not to exceed Technique or AA/ As mg/kg Arsenic 27 Gaseous Hydride or AA/Borohydride Reduction ICP/MS or ICP/MS or Not to exceed AA/ Direct Aspiration Cd mg/kg Cadmium compound 810 or AA/Furnace Technique Co-precipitation or Chromium 6 Cr+6 Not to exceed mg/kg Colorimetric or Chromium Hexavalent 640 Chelation/Extraction Pb Not to exceed mg/kg ICP/MS or ICP/MS or 237 Lead 750 AA/Direct Aspiration Not to exceed or AA/Furnace Mn mg/kg Manganese compound 32,000 Technique Not to exceed AA/Cold Vapor Hg mg/kg Mercury compound 610 Technique ICP/MS or ICP/MS or Nickel, soluble salts Not to exceed AA/Direct Aspiration Ni mg/kg Nickel 41,000 or AA/Furnace Technique ICP/MS or AA/Furnace Technique or Not to exceed Se mg/kg AA/Gaseous Hydride or Selenium 10,000 AA/Borohydride Reduction Continue table 8.2 Measurement Standard Unit Analysis method Pesticide Not to exceed mg/kg GC C8H14CIN5 Atrazine 110 Not to exceed C10H6Cl8 mg/kg GC/MS Chlordane 110 2,4-D Not to exceed GC or HPLC or mg/kg (C8H6Cl2O3) 12,000 TE/GC/MS DDT Not to exceed Dichlorodiphenyltrichloro e 120 mg/kg 238 (C14H9Cl5) thane Not to exceed C12H8Cl6O mg/kg Dieldrin 1.5 Not to exceed GC or GC/MS C10H5Cl7 mg/kg Heptachlor 5.5 Not to exceed C10H5Cl7O mg/kg heptachlor epoxide 2.7 ClCH(CHCl)4CH Not to exceed mg/kg Lindane Cl or C6 H6 Cl6 29 Not to exceed GC or GC/MS or Cl5C6OH mg/kg Pentachlorophenol 110 GC/FT-IR Other Chemical GC/MS or Not to exceed Benzo (A) pyrene C20H12 mg/kg TE/GC/MS or GC/FT- 2.9 IR Distillation or Total Cyanide compound Amenable Cyanide (Automated CN- Not to exceed mg/kg Colorimetric, with off- 35 line Distillation) or Cyanide Extraction Procedure for Solids and Oils PCB Not to exceed PCBs mg/kg GC Polychlorobiphenyls 10 239 Vinyl Chloride Purge and Trap GC or Not to exceed Vinyl Chloride CH2 =CHCl mg/kg Purge and Trap 8.3 GC/MS Chapter 4 Water Quality Article 9 General Water Quality Standards General water quality standards is indicator indicates chemical concentration volume and contaminated in surface water and underground water which defines general water quality for consumption and to ensure it will not effect to life, people’s health, animal and environment. Article 10 Surface Water Quality Standards Surface water quality is indicator indicates highest chemical concentration and contaminated in surface water which will not harmful and impact to life, people’s health, animal and environment based on each water resource category defines below: Table 10: Classification of Surface Water Quality Standards by each category Analyse Parameter Symbol Unit 1 2 3 4 5 Method Color, Oder Not N/A n n’ n’ n’ N/A Not identified and Taste identified Not Temperature t°C n n’ n’ n’ °C Thermometer identified potential of Not Not Electrometric pH 6-8 6-8 5-9 5-9 Hydrogen identified identified pH Meter 240 Dissolved Azide DO >7 6.0 4.0 2.0 <2 mg/L Oxygen Modification Electro- Ec <500 1000 2000 4000 >4000 µS/cm Ec meter conductivity Potassium Dichromate chemical Digestion; oxygen COD <5 5-7 7-10 10-12 >12 mg/L Open Reflux demand or Closed Reflux Multiple Tube Total Not Not Not MPN/100 Fermentation coliform identified n 5,000 20,000 identified identified ml Technique bacteria Multiple Tube Fecal Not Not Not MPN/100 Fermentation coliform n 1,000 4,000 identified identified identified ml Technique bacteria Total Glass Fiber Suspended TSS <10 25 40 60 >60 mg/L Filter Disc 241 Solid Phosphate PO4 <0.1 0.5 1 2 >2 mg/L Ascorbic acid Ammonium NH4 + <0.5 1.5 3 4 >4 mg/L Kjeldahl ion Not Nitrate- Cadmium NO3 -N n 5.0 identified mg/L Nitrogen Reduction Ammonia- Not Distillation NH3–N n 0.5 mg/L Nitrogen identified Nesslerization Distillation,4- Not Phenol C6 H5 OH n 0.005 mg/L Amino identified antipyrene Not Copper Cu n 1.5 mg/L identified Not Nickel Ni n 0.1 mg/L identified Not Manganese Mn n 1.0 mg/L identified Zinc Zn n 1.0 Not mg/L AA-Direct 242 identified Aspiration Not Cadmium Cd n 0.003 mg/L identified Not Chromium Cr+6 n 0.05 mg/L Hexavalent identified Not Lead Pb n 0.01 mg/L identified Not AA-Cold Mercury Hg n 0.001 identified mg/L Vapour Technique Not AA -Direct identified Aspiration, Asenic As n 0.01 mg/L ICP Not Pyridine- Cyanide CN- n 0.07 identified mg/L Barbituric Acid Radioactive Radioactive Not Becqurel/ - Alpha -α n 0.1 identified L - Beta - 1.0 Organochlorin e Not n 0.05 mg/L GC pesticide identified 243 Dichlorodiph Not enyltrichloro DDT n 1.0 µg/L identified ethane alpha- α -BHC Not Benzene n 0.02 µg/L (C6 H6 Cl6) identified hexachloride Not GC Dieldrin C12H8Cl6O n 0.1 µg/L identified Aldrin C12H8Cl6 n 0.1 Not µg/L identified heptachlor C10H5Cl7 and Not And N 0.2 µg/L heptachlor identified C10H5Cl7O epoxide Not Endrin C12H8Cl6O N Must be no show µg/L identified Notice: Category 1 Good quality natural water resources, no any production progress or chemical contamination and without wastewater from any type of activities. Category 2 Water resources for consumer and consumption but it need to be disinfected. This type of water is appropriate for aquatic conservation, fishery, and water sports and so on. 244 Category 3 Water resources for consumer and consumption but it need to be disinfected, this type of water is appropriated for agriculture livestock and so on. Category 4 Water resources for consumer and consumption but it need to be disinfected, this type of water is appropriate for industry, supports wastewater treatment from urban or community and so on. Category 5 Water resources utilized for communication, transportation, supports wastewater treatment from urban or community and so on. n: Natural Water Resource n’: Natural Water Resource but temperature has been changed ±3°C Article 14 Water Pollution Control Standards Water pollution control standards is indicator of the highest chemical concentration level, contamination in treated wastewater and dilution discharged to public canal or natural water resources and to ensure not to harmful and impacted to life, people’s health, animal and environment based on the Water Pollution Control Standards defined below: Table 14: Water Pollution Control Standards for General Factory parameter Symbol Allowed Standards Unit Analysed Method Not potential of Hydrogen pH 6-8.5 pH Meter identified Not over 2,500 mg/L depends on industrial Dry evaporation at Total Dissolved Solid TDS category and water mg/L temperature resources but not over 103-105 °C, 1 hour 5,000 mg/l. Not over 50 mg/L depends on industrial Total Suspended Glass Fiber Filter TSS category and water mg/L Solid Disc resources but not over 150 mg/L 245 Temperature T Not over 40 °C Temperature Meter Color and Odor Not Must be no show Not General identified identified Hydrogen Sulfide H 2S Not over 1.0 mg/L Titration CN- Distillation and Pyridine Barbituric Cyanide Not over 0.2 mg/L Acid 246 Not over 5.0 mg/L depends on industrial Solvent Extraction Fat, Oil and Grease FOG category and water mg/L by Weight resources but not over 15.0 mg/L Formaldehyde CH2 O Not over 1.0 mg/L Spectrophotometry Distillation and Phenol C6 H5 OH Not over 1.0 mg/L Aminoantipyrine Method 4 Chlorine Cl- Not over 1.0 mg/L Lodometric Method Pesticide - Must be no show mg/L GC Not over 30 mg/L depends on industrial Biological Oxygen Azide Modification BOD5 category and water mg/L Demand 5 Days at 20 °C, 5 days resources but not over 60 mg/L Not over 100 mg/L mg/L depends on industrial Total Nitrogen TKN category and water Kjeldahl resources but not over 200 mg/L Not over 120 mg/L Potassium Dichromate depends on industrial Chemical Oxygen Digestion ; Open COD category and water mg/L Demand resources but not over Reflux or Closed 247 Reflux 400 mg/L Heavy metals Zinc Zn Not over 5.0 mg/L Chromium Cr+6 Not over 0.25 mg/L AA/AES; ICP Hexavalent Chromium Trivalent Cr+3 Not over 0.75 mg/L Copper Cu Not over 2.0 mg/L Cadmium Cd Not over 0.03 mg/L Barium Ba Not over 1.0 mg/L AA/AES; ICP Lead Pb Not over 0.2 mg/L Nickel Ni Not over 1.0 mg/L Manganese Mn Not over 5.0 mg/L Arsenic As Not over 0.25 mg/L AA-Hydride 248 Selenium Se Not over 0.02 mg/L Generation or ICP AA - Cold Vapour Mercury Hg Not over 0.005 mg/L Techique Table 14.1: Category and Size of building to be controlled for Water Pollution Control Size Category A B C D E 100 rooms but 500 rooms or Less than 100 Not Not Condominium not over 500 over rooms identified identified rooms 200 rooms or 60 rooms but not Not Not Hotel <60 rooms over over 200 rooms identified identified 50 rooms but 10 rooms but Not Dormitory Not identified >250 rooms not over 250 not over 50 identified rooms rooms Massage 2 1,000 but not Not Not (or Similar) Not identified 5,000 m over over 5,000 m2 identified identified 30 beds or 10 beds but not Not Not Hospital Not identified over over 30 beds identified identified School, 25,000 m2 or 5,000 but not Not Not Not identified College, over over 25,000 m 2 identified identified Institute Office 55,000 m2 or 10,000 but less From 5,000 less Not Not 249 over than 55,000 m 2 than 10,000 m2 identified identified 25,000 m2 or 5,000 but less Not Not Not identified Shopping Center over than 25,000 m 2 identified identified 2,500 m2 or 1,500 but less 1,000 but less 500 but less Not Fresh Market over than 2,500 m2 than 1,500 m2 than 1,000 m2 identified Restaurant, 2,500 m2 or 500 but less than 250 but less 100 but less Less than Food court over 2,500 m2 than 500 m2 than 250 m2 100 m2 Table 14.2: Water Pollution Control Standards for Building Highest allowed by category Analysis Parameter Symbol Unit A B C D E Method Potential of Hydrogen pH 5.5-8.5 5.5-8.5 5.5- 5.5- 5.5-8.5 Not pH Meter 8.5 8.5 identified Azide Biological Oxygen BOD5 20 30 40 50 60 mg/L Modification at Demand 5 Days 20 °C, 5 days Glass Fiber Total Suspended Solid TSS 30 40 50 50 60 mg/L Filter Disc Not Imhoff Cone Sediment Solid SS 0.5 0.5 0.5 0.5 identified mg/L 1,000 cm3 1hour Not Dry Total Dissolved Solid TDS 500 500 500 500 identified mg/L Evaporation 103-105 °C, 1hour Not Sulfide S2- 1.0 1.0 3.0 4.0 identified mg/L Titration Nitrogen TKN 35 35 40 40 Not mg/L Kjeldahor 250 identified colormetric Solvent Fat, Oil and Grease FOG 20 20 20 20 100 mg/L Extraction by Weight Table 14.3: Water Pollution Control Standards for Housing Estate Highest allowed by Category (A) (B) Parameter Symbol 100 Houses but not Over 500 Unit Analysis Method over 500 Not Potential of Hydrogen pH 5.5-8.5 5.5-8.5 identified pH Meter Biological Oxygen Azide Modification Demand 5 Days BOD5 30 20 mg/L at 20 oC , 5 days Glass Fiber Filter Total Suspended Solid TSS 40 30 mg/L Disc Imhoff Cone 1,000 Sediment Solid SS 0.5 0.5 mg/L cm3 1hour Dry Evaporation Total Dissolved Solid TDS 500 500 mg/L 103-105 °C, 1 hour Sulfide S2- 1.0 1.0 mg/L Titration Nitrogen TKN 35 35 mg/L Kjeldahl Sovent Extraction Fat, Oil and Grease FOG 20 20 mg/L by Weight Table 14.4 Water Pollution Control Standards for Toilet Parameter Symbol Standards Unit Analysis Method 251 Not potential of Hydrogen pH 6-9 pH Meter identified Biological Oxygen Azide Modification at 20 oC BOD5 30 mg/L Demand 5 Days , 5 days Potassium Dichromate Chemical Oxygen COD 125 mg/L Digestion; Open Reflux or Demand Closed Reflux Total Suspended Solid TSS 50 mg/L Glass Fiber Filter Disc Total Nitrogen TKN 10 mg/L Kjeldahl Distillation and Phenol C6 H5 OH 2 mg/L Aminoantipyrine Method 4 Solvent Extraction by Fat, Oil and Grease FOG 5.0 mg/L Weight Total Dissolved Solid TDS 400 MPN/ml Dry Evaporation 103-105 °C, 1 hour 252 Table 14.5: Water Pollution Control Standards charging into public canal Parameter Symbol Standards Unit Analysis Method Not potential of Hydrogen pH 5.5-8.5 identified pH Meter Electro-Conductivity Ec 2,000 µS/cm Dry Evaporation Total Dissolved Solid TDS 1,300 mg/L 103-105 °C, 1 hour Biological Oxygen Azide Modification Demand 5 Days BOD5 30 mg/L at 20 oC , 5 days Total Suspended Solid TSS 30 mg/L Glass Fiber Filter Disc Per-manganese MnO4 - 6.0 mg/L Titration Hydrogen Sulfide H2S 1.0 mg/L Titration Distillation and Cyanide CN- 0.2 mg/L Pyridine Barbituric Acid Solvent Extraction by Fat, Oil and Grease FOG 5.0 mg/L Weight Formaldehyde CH2 O 1.0 mg/L Spectrophotometry Distillation and Phenol and Cresol C6 H5 OH 1.0 mg/L Amino antipyrine Method 4 253 Resident Chlorine Cl- 1.0 mg/L Iodometric Method Not Radioactive Must be no show mg/L General identified Not Color and Odor Must be no show mg/L General identified Not Tar Must be no show mg/L General identified Heavy Metal Zinc Zn 5.0 mg/L Atomic Absorption Chromium Hexavalent Cr +6 0.3 (AA) Arsenic As 0.25 Copper Cu 1.0 Mercury Hg 0.005 mg/L Atomic Absorption Cadmium Cd 0.03 (AA) Barium Ba 1.0 254 Selenium Se 0.02 Lead Pb 0.1 Nickel Ni 0.2 Manganese Mn 0.5 Table 14.6: Water Pollution Control Standards for Pig Farm Symbol Highest allowed Parameter Standards Standards Unit Analysis Method A B potential of Hydrogen Not pH 5.5-8.5 5.5-8.5 pH meter identified Biological Oxygen Not over AzideModificationor BOD 5 Not over 60 mg/L Demand 5 Days 100 Membrane Electrode Potassium Dichromate Chemical Oxygen Not over Not over Digestion; Open COD mg/L Demand 300 400 Reflux or Closed Reflux Glass Fiber Filter Disc, Not over Not over Total Suspended Solid TSS mg/L Dry Evaporation 150 200 103-105 °C Kjeldahl, Colorimetric Total Nitrogen TKN Not over Not over mg/L or Ammonia Selective 255 120 200 Electrode Notice: Standard A • Large scale farm having livestock more than 400 units • Medium scale farm having livestock more than 60 - 400 units Standard B Small scale farm having livestock from 6 but not over 60 units • 1 unit = 500 kg • Average weight of breeding pig = 170 kg/head • Average weight of fattened pig = 60 kg/head • Average weight of nrsering pig = 12 kg/head Table 14.7: Water Pollution Control for Car wash and Gas Station Duration and Parameter Symbol highest Unit Analysis Method allowed potential of Hydrogen Not pH 5.5-8.5 pH meter identified Chemical Oxygen Potassium Dichromate COD Not over 200 mg/L Demand Digestion Total Suspended Solid TSS Not over 60 mg/L Glass Fiber Filter Disc Extract with solvent after solvent evaporation is Fat, Oil and Grease FOG Not over 15 mg/L weighed to determine the oil and grease content. 256 Notice: For Industrial Park or having many factories located in the same location is identified specific standards. Chapter 5 Noise and Vibration Standards Article 15 General Noise Standards General noise standards are indicated by values measuring the sounds which will not disturb communication or have negative impacts on life, health, animals, or the environment, and which must be controlled according to the following standards: Table 15: General Noise Standard Standard How to measure the volume Maximum Volume (Lmax) is not to exceed 115 Measure the volume (Leq) while raising or Decibels, dB(A) lowering the level of noise Mean Volume 24 hours (Leq24) is not to exceed 70 Measure the volume (Leq) continuously dB(A) Table 15.1: Noise Control Standard Volume Standard How to measure the volume Difference in volume when When the sound disturbance lasts for 1 hour continuously, disturbing compared to measure the volume for 1 hour (L eq 1 hr) basic noise volume(L90) is When the noise disturbance lasts for more than 1 hour, not to exceed 10 dB(A) measure the volume based on the actual value. When the noise disturbance lasts discontinuously for 1 hour, measure the volume for 1 hour (L eq 1 hr) For some specific locations requiring silence, e.g. hospitals, schools, government offices, etc., or from 22:00h - 6:00h, measure the average volume over 5 minutes (Leq 5 min) and add more 3dB(A) 257 Table 15.2: Noise Control Standards for the machines and vehicles Standard Measuring method 1. Engine applied for navigation Measure from the tube end 0.5m, not to Diesel engines: Accelerate to the maximum exceed 100 dB(A) RPM of the machine Test 2 times by measuring the maximum Gas engines: Accelerate to 3/4 of the maximum value If it appears to be very different from RPM 2 dB (A), measure again Measure 7.5 m, Not to exceed 85dB (A) or Diesel engine: Measure while accelerating to maximum RPM of the engine Measure 0.5m, not to exceed 100 dB (A) Gas engines: Measure while parking and accelerate at 3/4 of maximum RPM 4. Engines applied for motorbikes Table 15.3: Sound Control Standards from mining activities and stone explosion Standard Volume Measurement The maximum volume should not Measuring the maximum volume by using Sound exceed 115 dB(A) Pressure Level (SPL) methods when crushing stone. Continuous volume(Leq) is 8 hours, not Measuring the average noise over 8 hours, use the to exceed 75 dB (A) continuous volume measuring standards for 8 hours when crushing stone. Continuous Volume (Leq) is 24 hours, Measuring the average noise over 24 hours, utilize not to exceed 70 dB (A) continuous volume measuring standards for 24 hours. Article 16 Vibration Control Standards Vibration Control Standards are indicated by values specifying levels of vibration which will not have negative impact on components or construction structures, as follows: Table 16: Vibration Control Standards from mining activities and stone explosion 258 Frequency (Hertz) Frequency Frequency Displacement (mm) Velocity (mm/s) Not to exceed Not to exceed 1 4.7 0.75 2 9.4 0.75 3 12.7 0.67 4 12.7 0.51 5 12.7 0.40 6 12.7 0.34 7 12.7 0.29 8 12.7 0.25 9 12.7 0.23 10 12.7 0.23 11 13.8 0.20 12 15.1 0.20 13 16.3 0.20 14 17.6 0.20 15 18.8 0.20 16 20.1 0.20 17 21.4 0.20 18 22.6 0.20 19 23.9 0.20 20 25.1 0.20 21 26.4 0.20 22 27.6 0.20 23 28.9 0.20 24 30.2 0.20 25 31.4 0.20 26 32.7 0.20 27 33.9 0.20 259 28 35.2 0.20 29 36.4 0.20 30 37.7 0.20 31 39.0 0.20 32 40.2 0.20 33 41.5 0.20 34 42.7 0.20 35 44.0 0.20 36 45.2 0.20 37 46.5 0.20 38 47.8 0.20 39 49.0 0.20 40 50.8 0.20 Table 16.1: How to measure vibration Measuring Instrument How to measure Installation Install the vibration- Use any material/equipment as the head stretching steel to measuring instrument on the stably measure the vibration in order not to make the surface measurement unit move the installation position when measuring. Install the vibration- Measure from the concrete at concrete surface or base level measuring head on concrete to the ground, not to exceed 0.5 m, by stretching the surface outside the buildings. measuring unit to keep the vibration measuring unit stable without moving. Chapter 6 Final Provision Article 17 Implementation Ministry of Natural Resources and Environment authorized to Department of Pollution Control to be in charged as well as centralized collaboration with other relevant and local authorities to disseminate and implement this agreement strictly and for the highest effective. 260 Article 18 Effective This agreement is effective since its promulgation after issuing of an official notice 15 days. Relevant can issues standards for pollution control by specified activities, but for the standards value must be under this agreement. Every term and provisions inconsistent of this agreement are hereby terminated. This agreement will be replaced the agreement on National Environmental Standards no. 2734/PMO-WREA, dated: 7 December 2009. 261 Attachments Description of chemicals specified in the agreement: Carbon monoxide (CO) is a gas without color, taste, smell, lighter than general air, and caused by incomplete burning of fuel which has carbon as an element. Impact on health: (CO) will enter to prevent red blood cell transport, which causes weakness and dizziness. If at a high dose, it can result in death. Nitrogen Dioxide (NO2) is a brown naturally occurring gas also produced by human activity such as burning fuel in an industrial factory, high-temperature engines and vehicle combustion. Impact on health: it can damage lungs, resulting in pneumonia and bronchitis. Combined with water, it becomes acidic, causing irritation to respiratory system, nose and eyes. With exposure to greater volumes, it can cause death. Ozone (O3) is a gas arising from photochemical smog from oxides of nitrogen and hydrogen, with the sunlight as an accelerator resulting in the creation of ozone. Impact on health: Overexposure to ozone can cause burning eyes, irritation to respiratory systems, and in serious cases, skin cancer. Sulfur Dioxide (SO2) is a gas without color, flame, or smell, and caused by fuel combustion in combination with sulfur dioxide. Impact on health: If this chemical enters into the body, it will cause a faster pulse, neck itching, burning eyes, and chest pain. Diffused in the atmosphere, it will transform into SO3 in combination with water and become acidic H2SO4, and later acid rain. Lead (Pb) is a flexible metal, its color a mix of white and blue but in contact with the air it will turn grey. It is a heavy metal which is poisonous and is a product utilized in processing certain raw materials, bacteria, electric appliances, zinc, and container coatings. Impact on health: Negative impacts on nervous system and brain, headache, weakness, anorexia, muscle pain, pain in fingers and toes, loss of feeling, negative effects on brain development of children, the heart, anemia, high blood pressure, the reproductive system and unborn babies. Total Suspended Particulate (TSP) of 100 microns is a small amount, arising from nature and human activity such as forest fires, dust, smoke from transportation, construction, production, processing and mining industries etcetera. Impact on health: Impact on hygiene of living things, cough, bronchitis, especially those who have respiratory system problems, such as asthma, and can damage buildings, houses, and cause suffering to people and obscure vision of obstacles. Particulate Matter 10 (PM10): a small amount equivalent to 10 microns is able to enter into the human body. 262 Impact on health: Impact on hygiene of living things, cough, bronchitis, especially those who have respiratory system problems, such as asthma, and can damage buildings, houses, and cause suffering to people and obscure vision of obstacles. Particulate Matter 2.5 (PM2.5): a small amount equivalent to 2.5 microns is able to enter into the human body and affect the respiratory system and be absorbed into the blood. Impact on health: Impact on hygiene of living things: coughing and lower respiratory system diseases such as emphysema, and damage to buildings, houses, and causing suffering to the people and obscures vision of obstacles. pH (potential of Hydrogen) is a type of carbon found in chemical solutions ranging from 1- 14. The level of neutral Ph is 7. Impact on health: Impact on living things when pH is lower than 4, which is acidic and makes living things unable to live, and there are negative impacts on living things when pH is over10. Dissolved Oxygen (DO) refers to a quantity of oxygen dissolved in water as an important indicator for living things in water resources. Impact on health: Low value of DO affects organisms’ ability to survive. Biochemical Oxygen Demand (BOD5) refers to the quantity of oxygen that microorganisms need to digest organic compounds in water where the temperature is 20°(C) for 5 days. Impact on health: The value of BOD5 is an indicator of water quality. If the value of BOD5 is high, the water is unclean due to high level of organic compounds in water, and this affects organisms’ ability to survive. Chemical Oxygen Demand (COD) is the quantity of oxygen used to digest the organic compounds by using the chemicals for wastewater analysis is in the laboratory. In general, the value of COD is more than BOD. Impact on health: The value of COD is an indicator of the water quality as BOD5. It is unclean water due to high contamination in water and affects organisms’ ability to survive. Electrical conductivity (EC) is the ability of water to conduct electricity and is based on the total concentrations of ions in water. Impact on health: The value of EC is an indicator of the ion contamination of water. If the value of EC is high, water in the river has a high concentration of ions. Total Dissolved Solids (TDS) indicates the quantity of all small solids in water flowing through a standard filter, calculated from evaporation of water through a filter. Impact on health: Suspended solids contaminate water and exert changes that differ according to the concentration and temperature. Total Suspended Solids (TSS) refers to the quantity of solids in a standard filter, calculated from bringing the filter to a bake in order to evaporate water. Impact on health: Makes water turbid and prevents sunshine from penetrating water. 263 Water Temperature (t°C) refers to water temperature during discharge into a natural water resource, which may directly or indirectly affect living things in the aquatic environment. Impact: If water temperature is too high, it may decrease the concentration of oxygen dissolved in the water. Cadmium (Cd) is a heavy, shiny, light silver metal without smell. Impact: Impact on the respiratory system, may cause lung cancer, kidney damage, and is potentially fatal. Mercury (Hg) is a white, silver-like metal, liquid at normal temperatures. Impact: Dangerous to central nervous system, brain, and spine, resulting in loss of control, lung cancer, chest pain, diarrhea, dizziness, and bleeding, is potentially fatal. Hydrogen Chloride (HCl) is a form of acidic gas. Impact: Causes irritation of nose tissue, neck, upper respiratory system, obstruction of the respiratory system, heart attacks, is potentially fatal. Hydrogen Fluoric (HF) is a form of acidic gas with a strong odor. Impact: Dangerous to tissue in the respiratory system, causing cough, throat irritation, burning nose, bronchitis and lung cancers. Dioxins are chemical compounds caused by burning or incomplete production related to chlorine. Impact: Impact on liver, the immune system of the body, the nervous and reproductive systems and may even cause cancer. Hydrogen Sulfide (H2S) is a gas, which smells like a rotten egg, and it is flammable. Impact: Causes tissue irritation, damage to lungs, kidneys, the gastrointestinal and digestive systems, and may affect unborn children. Xylene (C8H10) is a flammable liquid. Impact: It is dangerous to swallow and may result in death when it enters the respiratory system. It also irritates the skin. Cresol (C7H8O) smells like disinfectant. Impact: Causes irritation of the eyes, mouth, neck and can contribute to cancer. Antimony (Sb) is a semi-metallic, dangerous in gaseous form. Impact: Causes coughing, rashes and skin pain and is a carcinogen. Arsenic (As) is a naturally occurring semi-metal. Impact: Causes headache, diarrhea, muscle tension, thick skin, black spots on the skin, pain in fingers and toes, skin cancers and lung cancers as well as affecting unborn children. Copper (Cu) can be found in nature. 264 Impact: Over exposure causes headache, nausea, diarrhea, abdominal and muscle inflammation, causes heart and lung disorders and anemia. Chlorine (Cl) is a yellowish gas with strong smell. Impact: Destroy the nervous system and tissues. Color) and Turbidity) means substances suspended in water such as soil, sediment, organic compounds, inorganic compounds, plankton, and small-scale living things. Impact: Prevents sunlight shining into the water. Taste Water naturally has no taste (fresh). If the taste of water becomes sour or salty, it may be contaminated water and not suitable to drink. Iron (Fe) Impact: At high concentrations it may cause iron poisoning, nausea, diarrhea, bloody diarrhea, stomach ulcers, serious dehydration, and even death. Manganese (Mn) is a white silver-like metal. It is fragile and is seen in nature in combination with other substances. Impact: It causes chronic poisoning of the central nervous system, and periodic headache, muscle pain, insomnia, spasms, and sometimes it causes paralysis of body parts. Zinc (Zn) is a shiny, silvery substance primarily used in industry. In small amounts it is necessary in humans and animals to stimulate the construction and repair the epidermis, and for collagen synthesis, helping in processes of creating enzymes and building the immune system. Impact: The dust or vapor of zinc oxide may result in failure of the respiratory system potentially causing death. If touching the skin for an extended period of time it causes serious inflammation. When the body comes into contact for an extended period, it makes the enzyme of the liver work abnormally. Calcium (Ca) is a necessary substance for living things. Impact: Lack of calcium can cause osteoporosis, muscle and nerve spasms, numbness, seizures, abnormal blood. Too much Calcium can cause constipation and kidney failure. Magnesium (Mg) is a mineral which helps many types of enzymes in the body work properly, as well as nerve cells and muscle. The body requires a small amount of it. Impact: If Magnesium (Mg) in the blood is high, it may cause nausea, diarrhea, low blood pressure, or heart disorders. It can cause weakness, insensible feeling, seizure and the muscle is totally weak. Sulfate (SO4) is a mineral formed from natural salt which causes water to become hard (permanent hard water) making it necessary to adjust water conditions. It contains salt of sulfuric acid or surfactant which help in removing certain contaminants and can cause bubbles to form. Fluoride (F) is a substance found in the body which can be seen in bones and teeth. 265 Impact: Too much Fluoride (F) may cause intestinal illness and nausea and may affect the respiratory system or even result in death. Alkylbenzenesulfonate (C18H29NaO3S) is a surfactant chemical and a component in dishwashing liquid and detergent. Impact: It is a mildly dangerous chemical which causes irritation if eaten and may cause a sore mouth and tongue, nausea, or diarrhea. It is not easily dissolved in the environment. Bubbles from the liquid can make oxygen dissolve in the water at a low level and prevent sunlight from penetrating water, which can render it putrid. Phenol (C6H6O) is a component of hydroxyl, connecting with a benzene ring. Impact: Destroys water quality and affect living things negatively, it is a carcinogen, poisonous to the central nervous system, kidney, liver and pancreas. It causes burns to skin. Selenium (Se) is used in 3 industries: electronics, ceramics, and steel. It is mildly poisonous by itself, but in some compounds is very toxic. Impact: in a large quantity it will cause nausea, diarrhea, loss of nails and hair, and lesions on the skin and in the nervous system. Chromium Hexavalent (Cr+6) is a metal widely use in industries such as electrical metal welding. It is a silvery solid without smell, with a high welding point, and it is malleable. Impact: Breathing the dust or vapor of Chromium Hexavalent (Cr+6) can damage the upper respiratory system and cause lung cancer and skin inflammation. Cyanide (CN) indicates all ions of Cyanide (CN) which are component substances in metallic alkaline and heavy metals and can be found in plants in the form of hydrocyanic acid. Impact: Stops growth, suppresses the process of cell creation and digestive cells of living things, including respiratory processes and blood circulation and the central nervous system. Barium (Ba) Impact: Barium vapor is very toxic, and all types of Barium compounds can dissolve in water. Some compounds are muscle stimulants, but it is toxic for heart, causes excess salivation, high pulse rate, high blood pressure, limb paralysis is and bloody diarrhea. Bacteria Standards Plate Count Method is a contamination indicator of water containing various types of pathogens. Impact: As a water contaminant, it may spread and affect the health of consumers. Total Coliform Bacteria is a microorganism found in human excrement and warm-blooded animals. It lives in the large intestine. Bacteria such as Escherichia do not cause disease. Impact: As a water contaminant it may spread and affect the health of consumers. E. Coli is pathogenic microorganism. Impact: When it is contaminated into water, it will scatter and affect the health of consumers, which can cause diarrhea, nausea, fever, tiredness and weakness. Total Hardness (CaCO3) refers to hardness of water due to dissolved calcium. 266 Impact: Waste of liquid washing detergent because it is hard to dissolve in the water and cause strain and clogging in washing machines. Silver (Ag) is a metal used to produce material, jewels and disinfectants. Impact: When a compound of silver enters into our body, it may be absorbed by the blood circulatory system and the silver is left in organs, causing grey spots on the skin. Aluminum (Al) is a lightweight heat-resistant metal which reflects light and heat. Impact: Consumed in large quantities for a long period, it will make bones, muscles, and limbs thin and fragile, easily infected, and damage the kidney and other organs. Radioactive substances produce high-energy radiation, transforming elements into new atoms. Impact: In large quantities, it will cause loss of molecular balance in water and organic and inorganic compounds in the body, with negative impacts on cells which may cause illnesses or even death. Pesticides are in a group containing organic chlorine components. Impact: impact on the central nervous system, causing restlessness, dizziness, unbalanced growth, and seizures. In large quantities it will cause heart attack and even death. At present, it is prohibited to use pesticides which can persist in the environment. Includes DDT, Alpha BHC, iodine, heptachlor epoxide. ƒ Fat, Oil and Grease (FOG) are organic compounds derived from tissues of plants and animals and insoluble in water. Impact: Make water odorous, undrinkable. ƒ Formaldehyde is a colorless substance used in the colored glue and furniture protection liquid industries. Impact: In small quantities it may cause the irritation of eyes, nose and respiratory system. In large quantities it can cause unconsciousness and even death. Long term impacts include higher risk of cancer. ƒ Total Nitrogen (TKN) is a value of nutrients necessary for the eco-system in the correct concentration. It is found in nitrites, nitrates, and ammonia, which are used as plant fertilizers dissolved in water. Impact: Decreases dissolved oxygen in water arising from metabolism of microorganisms and leads to eutrophication. Ammonia is directly toxic for aquatic animals. Nitrites cause difficulty for gas transport in the blood. ƒ Volatile Organic Compounds (VOCs) is a compound which at regular temperatures is liquid, volatile and flammable. Impact: It can be absorbed into the skin, nose, and mouth, causing respiratory problems, weakness, and nervous system damage. Over longer periods it can cause cancer. ƒ Benzo (A) pyrene (C20H12) is a compound of polycyclic aromatic hydrocarbons (PAHs), arising from incomplete combustion of organic compounds and using a kiln to burn coal or wood. 267 Impact: causes cancer and cell mutations. ƒ Polychlorobiphenyls (PCBs) is a group of chlorine chemicals which are main components of liquid substances which dissolve less well in water than in fat. PCBs are resistant to oxidation and heat and hard to dissolve in the environment. Impact: PCBs will accumulate in the body, causing anorexia, nausea, swollen limbs, blisters, skin defects, an abnormal immune system, and cancer. ƒ Vinyl Chloride (CH2=CHCl) is a colorless gas, liquid when it under pressure in tanks, and used as a raw material to produce PVC. Impact: causes numbness when in contact with skin and causes skin irritations, pain in extremities such as fingers and a potential factor in liver cancer. Minister Sommad PHOLSENA 268