ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN (ESMP)

advertisementhumphΔιαχείριση

9 Νοε 2013 (πριν από 3 χρόνια και 9 μήνες)

211 εμφανίσεις

1



ENVIRONMENTAL A
ND SOCIAL MANAGEMENT PLAN (ESMP)

Revitalizing and Strengthening the Health Service Delivery in Crises affected Districts of Khyber Pakhtunkhwa
under Public Private Partnership



June

2013





Health Department, Government of Khyber Pakhtunkhwa

Health Sector Reforms Unit (HSRU)



ACKNOWLEDGEMENT



The
author acknowledges

the cooperation and support of
Health Sector Reforms Unit (HSRU)
,
Department

of Health

Government of
Khyber Pakhtunkhwa

in completing this assignment.
Besides, the author is indebted to a valuable discourse
and information sharing
with
the World Bank,
Provincial Disaster Management Authority (PDMA),
District Health Officer Buner,
Medical Superintendent
District Head Quarter Hospital Buner, the Law, Justice and Human Rights Department and Environmental Protection Agency Khyber

Pakhtunkhwa

regarding the proposed project.


DISCLAIMER


This document is issued for the party which commis
sioned it and for specific purposes connected with the above

captioned project
only. It will not be relied upon by any other party or used for any other purpose.


N
o responsibility
is accepted
for the consequences of this document being relied upon by any
other party, or being used for any
other purpose, or containing any error or omission which is due to an error or omission in data supplied by other parties.


Dated: May, 2013



TABLE OF CONTENTS


Acronyms

5

Executive Summary

8

1

CHAPTER
-
1:
INTRODUCTION

14

1.
1

Millennium
De
velopment Goals (MDGs)

14

1.
2

Comprehensive Development Strategy (CDS)


14

1.
3

Baseline


Current
Health
facilities and practice of PPP

15

1.
4

Description of Project

16

1.
5

Project
development objective

18

1.
6

Key
results

19

1.
7

Key performance indicators

19

1.
8

Components of the project

19

1.
9

Project
implementation

24

1.
10

Environmental and Social Screening and Assessment
Framework

25

1.
11

Objectives of ESMP

2
5

1.1
2

Project Management Organization

2
6

1.1
3

Project Steering Committee (PSC)

2
6

1.1
4

Project Management Unit

2
6

1.1
5

Management of Construction Activities

2
7

1.1
6

District Health Management Team

27

1.1
7

Procurement of Contracts


IPs Selection

2
7

1.1
8

Funds Disbursement Mechanism

2
7

1.1
9

Stakeholder consultation

2
8

2.

CHAPTER
-
2: REVIEW OF POLICIES AND LEGISLATION

36

2.1

Pakistan Environment Protection Act


1997

36

2.2

Protection of Women Against Harassment Act, 2010

39

2.3

Pakistan Employment of Children Act, 1991

39

2.
4

World Bank

Operational Policy OP 4.01

40

2.5

World Bank Operational Policy OP 4.12


Involuntary
Resettlement

40

2.6

World Bank OP/BP 4.10


Indigenous People

41

2.7

World Bank OP 11.03


Cultural Property

41

2.8

World Bank OP 4.04


Natural Habitats / OP 4.36


Forestry

41

3.

CHAPTER
-
3: IMPACT ASSESSMENT AND MITIGATION
PLAN

42

3.1

Screening of Project Activities

42

3.2

Impact Assessment and Key Issues

42

3.3

Environmental impacts of demolition and excavation
activities and mitigation

46

3.4

Environmental
impacts of construction activities and
mitigation

47

3.5

Environmental impacts of health facility operation and
mitigation

49

3.6

Environmental and social Mitigation Plan

56

3.7

Institutional Arrangements

68

3.8

Roles and Responsibilities of Officers

68

3.9

Monitoring

70

3.10

Reporting

70

3.11

Capacity Building and Training Plan

71

3.12

Public Disclosure

72

3.13

ESMP Cost

73

Table
-
1
:

Environmental and Social Impact Assessment matrix

43

Table

-
2
:

Environmental and Social Mitigation and Monitoring


Plan

57

Table
-
3:

Roles and Responsibilities of officers

at Construction


Phase

68

Table
-
4:

Roles and Responsibilities of officers at O&M Phase

69

Table
-
5:

Capacity Building and Training Plan

72

Table
-
6:

ESMP Cost for the project Period

73




ACRONYMS


ADP:


Annual Development Plan

AHF:


Abasin Health Foundation

AKHS:


Agha Khan Health Services

ANC:


Anti Natal Care

APC:


Assistant Project Coordinator

BHU:


Basic Health Unit

CDS:


Comprehensive
Development Strategy

CERD:


Center of Excellence for Rural Development

CPH:


Coordinator Public Health

CSO:


Civil Society Organization

DA:


Designated Account

DC:


Deputy Commissioner

DCO:


District Coordination Officer

DDHO:


Deputy District Health Offic
er

DFO


Divisional Forest Officer

DHIS:


District Health Information System

DHMT:


District Health Management Team

DHO:


District Health Officer

DHQ
H
:


District Head Quarter

Hospital

DOFP:


District Officer Finance and Panning

DOH:


Department of Health

DPWO:


District
Population Welfare Officer

NOC:


No Objection Certificate

EA:


Environmental Assessment

EHS:


Environment, Health and Safety

EIA:


Environmental Impact Assessment

EMOC


Emergency Medical and Operation Care

EMP:


Environmental Management
Plan

EOIs:


Expression of Interests

EPA:


Environmental Protection Agency

EPI:


Expanded Program for Immunization

EPP:


Emergency Project Paper

ESA:


Environmental and Social Assessment

ESFP:


Environmental and Social Focal Person

ESMP:


Environmental and
Social Management Plan

ESS


Environmental and Social Specialist

ESSAF:


Environmental and Social Screening and Assessment Framework

FATA:


Federally Administered Tribal Areas

FBS:


Fixed Budget Selection

FPHC:


Frontier Primary Health Care

HCP:


Health
Care Provider

HCW:


Health Care Waste

HD:


Health Department

HIV / AIDS

Human immunodeficiency Virus / Acquired Immunodeficiency Syndrome

HSRU:


Health Sector Reforms Unit

HWMAC:

Hospital Waste Management Advisory Committee

HWMR:

Hospital Waste Management
Rules


ICB:


International Competition Bidding

IDPs:


Internally Displaced Persons

IEE:


Initial Environmental Examination

IFC:


International Finance Corporation

ILO:


International Labor Organization

IMC:


Independent Monitoring Consultant

IP:


Implementation Partner

IT:


Information Technology

KP:


Khyber Pakhtunkhwa

LHW:


Lady Health Worker

M&E:


Monitoring and Evaluation

MDTF:


Multi Donor Trust Fund

MNCH:


Maternal Neonatal Child Health
c
are

MOU:


Memorandum of Understanding

MS:


Medical Supe
rintendent

MU:


Management Unit

NBP:


National Bank of Pakistan

NEQS:


National Environmental Quality Standards

NGO:


Non Governmental Organization

O&M:


Operation and Maintenance

OP

/ BP
:

Operational Policy

/ Bank Procedures

OPD:


Out Patient Department

PAPs:


Project Affected People

PC:


Project Coordinator

PCNA:


Post Conflict Need Assessment

PEPA:


Pakistan Environmental Protection Act

PHSA:


Provincial Health Services Academy

PKR:


Pakistani Rupees

PM&EC:

Provincial Monitoring and Evaluation
Committee

PMU:


Project Management Unit

PNRA:


Pakistan Nuclear Regulatory Authority

PPE


Personal Protective Equipment

PPHI:


People’s Primary Health Care Initiative

PPP:


Public Private Partnership

PRCS:


Pakistan Red Crescent Society

PSC:


Project Steer
ing Committee

PSC:


Provincial Steering Committee

PU:


Project Unit

RHC:


Rural Health Center

SC:


Supervisory Consultant

SOPs:


Standard Operating Procedures

SRSP:


Sarhad Rural Support Programme

TB


DOTS:

Tuberculosis


Directly Observed Treatment Short

Course

THQ:


Tehsil Head Quarter

TPE:


Third Party Evaluation

TPV:


Third Party Validation

VETS:


Vehicular Emission Testing Station

WB:


World Bank

WMO:


Waste Management Officer

WMP:


Waste Management Plan

WMT:


Waste Management Team



Executive Summary


The present Environmental and Social Management Plan (ESMP)
has been prepared for

the
Revitalizing and Strengthening the
Health Service Delivery and Nutrition Services in Crises Affected Districts of Khyber Pakhtunkhwa under Public Private Partne
rship

project
.
The project is being

implemented by the
Health Sector Reforms Unit (HSRU)
,
Department of Health (DoH), Government of
Khyber
Pakhtunkhwa

(KP)
. The initiative has been
financed by World Bank (WB) under the Multi Donor Trust Fund (MDTF).

The
ESMP ha
s been prepared in compliance with the national regulatory requirements and WB operational policies.


The project intends to address issues related to enhanced level of ongoing militancy and devastating floods of 2010 as contai
ned in
the Post Crises Need A
ssessment (PCNA). The PCNA
has been

carried out to determine status of damages to various sectors
including health. With regard to health sector, PCNA aims to reinforce the effectiveness of state response for restoring citi
zen’s trust
by revitalizing, stre
ngthening and sustaining the delivery of quality health care services in selected post
-
conflict / crisis affected
districts across
KP
.


The project will
also broadly
support the
commitment of the Government of Pakistan
for achieving

the Millennium
Development
Goals

(MDGs)
, which, inter
-
alia,
embod
y

universal primary education, access to health and drinking water, gender equality and
women empowerment, reducing child mortality and improving mother health, combating h
uman immunodeficiency virus / acqu
ired
immunodeficiency syndrome (HIV/AIDS)
, malaria and other diseases and ensuring environmental sustainability and developing
global partnership for development.


The provincial government has also approved a Comprehensive Development Strategy (CDS) for 2
010
-
2017. On the basis of CDS, a
health sector strategy has been prepared. The proposed project will strive to improve health status in Khyber Pakhtunkhwa thr
ough
ensuring access to a high quality, responsive healthcare delivery system which provides accep
table and affordable services in an
equitable manner.


The proposed project is being implemented in six districts of KP

i.e. Battagram, Buner, Dera Ismail Khan, Dir Lower, Kohistan, and Tor
Ghar for a period of three years. Its total outlay amounts to US$ 16 million.
The project aims at reduction in the morbidity and
mortality in most common illnesses especially among the v
ulnerable groups, by (a) enhanced coverage, quality and access to
essential health care especially for the poor and the vulnerable; and b) improved DoH’s ability and systems for accountabilit
y and
stewardship functions.
The project has
three major componen
ts i.e. i) r
evitalizing health care services, ii)

rehabilitation of health
infrastructure in the districts, and iii) establish and operationalize a robust monitoring and evaluation system at the distr
ict and
provincial levels.


The ESMP has been prepared i
n compliance with the World Bank Operational Policy 4.01, which requires environmental assessment
of projects proposed for Bank financing. The Plan essentially seeks to effectively implement the Hospital Waste Management Ru
les
-

2005, framed by the Govern
ment of Pakistan. The Plan also broadly complies with the Pakistan Environmental Protection Act (PEPA)
-

1997, which requires the proponents of every development project in the country to submit either an Initial Environmental
Examination or an Environment
al Impact Assessment to the concerned Environmental Protection Agency. The main objective of this
assignment is to institutionalize the ESMP

in the DoH’s HSRU Programme of KP, supported by World Bank under MDTF.


Amongst numerous planned activities, the pr
oposed project will undertake reconstruction, up
-
gradation, renovation and operation
and maintenance of public health facilities in six districts of Khyber Pakhtunkhwa.
These activiti
es

may cause negative social and
environmental impacts. To minimize these

impacts the present ESMP has been prepared
in accordance with the World Bank’s
guidelines and safeguard policies, guided by Operational Policy / Bank P
rocedures

4.01.


The proposed project having been classified as Category B

in accordance with the provis
ions of the WB OP 4.01
, with likely low to
medium level of adverse effects on human population and natural habitat, only warrants preparation of the ESMP. The ESMP
contains an assessment of environmental impacts associated with i) rehabilitation, reconstru
ction, and ii) operation and
maintenance of large and small scale hospitals.


Environmental Impacts of Demolition
/

Reconstruction

Activities and Mitigation


Health
care

facilities which are partially or completely damaged would require demolition
. Subsequently, construction activities will
be carried out at these facilities.
Such activities
are likely to
cause

some

impact
s

such as

air contamination
,
soil and water
contamination, increased vehicular traffic,
disposal of
debris, noise,
safety and he
alth hazards for the works and nearby
communities
. Dust pollution will be reduced through water sprinkling. Debris will be disposed off at municipality dumping sites or be
reused by locals as filling material. The impact of noise produced during constructi
on works will be reduced by carrying out civil
works during day time only. Furthermore compliance to
National Environmental Quality Standards (
NEQS
)

will also be ensured. For
pedestrians, safety
construction barriers will be erected to direct pedestrians s
afely around the demolition, excavation or
construction sites.


Preference will be given to the local people for employment on skilled and unskilled jobs in the proposed project activities
to
enhance their livelihood. Equal opportunities of employment will

be provided to men and women, where possible.


During reconstruction of buildings the construction contractors will provide personal protective equipments (PPEs) such as gl
oves,
boots,
and
helmets, to ensure health and safety of workers. A first aid box will be provided by the contractor at the construction
sites to cope with accidental cuts and injuries during work. Firefighting equipment will be installed in all health facilitie
s at identi
fied
places.


Environmental impacts of health facility operation and mitigation:


O
peration of health facilit
ies

is likely to create
most
significant

environmental and social impacts
including

severe health risks for the
nearby communities and waste handlers, health and safety risks for the facility staff,
soil and water contamination.
The ESMP
contains a detail assessment of
these
key environmental and social issues. The most common impacts or
iginating from
operation
and maintenance (
O&M
)

of hospitals and their mitigation are as follows:


Health hazards associated with
m
edical
w
aste
m
anagement
.
Improper handling, transportation and disposal of infectious and
other risk wastes pose serious health hazards for the waste handlers and community at large.
These concerns will be adequately
addressed by strictly following the Hospital Waste Management R
ules of 2005. These Rules call for preparing a waste management
plan

and

establishing a waste managemen
t team in each healthcare facility.


Safety risk
: S
afety hazards in the hospitals are generally associated with handling of sharp
s

(needles, cutters)
, gases, autoclaves, and
other similar equipment. Open burning of hospital waste also poses safety risks for the staff involved in the activity. These

hazards
include risk of cuts, pricks, gas poisoning, burning, and other bodily injuries. The healthcare f
acility staff as well as patients are
susceptible to these safety hazards. Strictly following standard operating procedures to use sharps and proper use of persona
l
protective equipment (PPE) particularly prick
-
proof gloves and masks is of foremost importa
nce to avoid safety hazards associated
with sharp instruments, gases, and other hazards. In addition, thick / puncture
-
resistant plastic bags to collect hospital waste and
rigid / puncture proof boxes to dispose needles / other sharps shall be used.

The

W
orld Bank Group’s

Environment, Health
,

and
Safety (EHS)

Guidelines will also be applicable to address the safety hazards as discussed above.


Safe Drinking Water
:
A

reliable and safe drinking water source will be made available at each hospital / health f
acility. Water will be
periodically tested against NEQS for drinking water.


Sewage disposal
: The building
s

will be connected to the municipal sewer system that serves the local area. However, the sewage
will be pre
-
treated in a septic tank to reduce its pollution load before discharge into the open drains, if municipal sewer does not
exist.


Gender issues
: The operation of health care facilities employs both male and female workers and may result into gender issues if
appropriate measures are not implemented as per local code of conduct i.e. female staff should adequately cover their body as

per
local norm
s, provision of separate recreational, residential, day care and separate toilet facility for male and female staff be made
part of the facility before operation.


Environmental and Social Mitigation Plan


A

detail
ed

environmental and social mitigation pla
n

(ESMP)
, including the required mitigation
measures
, has been prepared which
shall be used by the Implementing Partners and construction contractors during execution of project activities.


Institutional Arrangements


The Chief Health Sector Reform Unit (
HSRU), under the overall administrative supervision of Additional Secretary (Development) will
be responsible for the overall implementation of the ESMP in the province. He / she will be supported by a Project Coordinato
r. In
addition a full time Environme
ntal and Social Specialist (ESS) will be hired for effective implementation of ESMP. He / she will be
reporting to the Chief / Project Coordinator HSRU. The incumbent ESS will be responsible for overall coordination, effective
implementation, monitoring, a
nd progress reporting of ESMP at the provincial and district levels, in collaboration with project
stakeholders.


To ensure timely completion of planned civil works and quality construction, independent supervisory consultants (SC) will be

hired
by HSRU fo
r the overall supervision of civil works. The Assistant Project Coordinator (APC) / civil engineer hired by HRSU will also
assist in periodic monitoring and inspection of civil works during his
/her

routine visits to various sites.

Similarly the DHO along w
ith
his / her team of concerned district will be responsible for inspection and monitoring the work of the construction at the si
te. The SC
and APC will ensure ESMP compliance at each construction site.


D
uring the O&M phase of the project, the services of

an independent implementation partner (IP) will be engaged to operate the
health care facilities. The IP will be responsible for the effective implementation of ESMP, particularly the Waste Managemen
t Plan
(WMP) at
each
health care facility.

ESMP
Monitoring


Construction phase:

The Supervisory Consultants (SC) will be responsible for ESMP monitoring at the field level on a regular basis,
while the ESS will carry out random monitoring visits for this purpose.


O&M Phase:

At the provincial level, in
ternal monitoring of ESMP will be carried out regularly by the ESS to ensure that Implementing
Partners comply with the ESMP. He / she will be assisted by DHO and Deputy District Health Officers with monitoring responsib
ility
at
the district level
. The DHO

will be the liaison officer for coordination at the district level and Chief HSRU will coordinate with the
provincial health authorities and the donors for ESMP related issues. Non
-
compliances will be reported to the Chief
,

Health Sector
Reforms Unit and
Project Coordinator PMU for taking appropriate corrective actions.


External Monitoring
:

External monitoring will be carried out through an independent Third Party Validation (TPV) consultant on an
annual basis to evaluate the quality of work and overall p
rogress on ESMP implementation, and to ensure that the mitigation
measures are implemented as per the mitigation plan. The objective of external monitoring is to validate the monitoring data
already collected and to identify gaps and non
-
compliance issues,

if any, for mid
-
course correction. In case of any deviation,
corrective actions will be taken, where necessary.


Reporting


The
ESS
will be responsible for preparation of the monthly, quarterly and annual progress reports pertaining to ESMP, and
submissi
on of reports to the Health Department and donors, through the Chief HSRU. The ESS will develop the ESMP reporting
format during the course of project implementation. The report will contain the following main information:


i)

Brief account of ESMP

ii)

Monitorin
g objectives.

iii)

Brief capture from field inspections

iv)

Quantitative data analysis

v)

Summary of compliance and non
-
compliance.

vi)

Gaps and issues in implementation

vii)

Recommendations


Capacity building and training plan


Construction Phase
.

The ESS will impart appropriate trainings on ESMP
at the provincial level
. Similar trainings will also be imparted
by SC and construction contractors

at the field level
.


O&M phase
.

Capacity building of the project and health department staff associated wi
th ESMP implementation will be carried out
through trainings. The ESS will be responsible for imparting training at the provincial level, while a designated Waste Manag
ement
Officer (WMO) will be responsible for such trainings at the facility level. The ca
pacity building and trainings
will

be a continuous
process to enhance understanding and knowledge of staff pertaining to environmental and social issues on a regular basis duri
ng
the project period.


ESMP Cost


The cost for ESMP implementation has been est
imated to be PKR
7
.32 million. This includes the cost of hiring of a full
time

ESS,
capacity building of health facility staff,
field
monitoring

by ESS
,

and third party validation through an independent consultant for
quality assurance.
This cost will be
covered through the Technical Assistance (TA) component of the Project.


In accordance with the WB disclosure requirements
,

the present

ESMP will be disclosed to the public through websites of
implementing entities and distribution of executive summary in
Urdu and English to the stakeholders.



1.

INTRODUCTION


In order to address issues related to
enhanced level of militancy and devastating floods of 2010 a
Post Crises Need Assessment
(PCNA)
was
carried out to determine
status
of damages to various sectors including health.
With regard to health sector
, PCNA aim
s

to
build responsiveness and effectiveness of the state to restore citizen’s trust by revitalizing, strengthening and sustaining
the
delivery of quality health care serv
ices in the post
-
conflict

/

crisis affected districts across Khyber Pakhtunkhwa.

Resultantly,
the
Revitalizing and Strengthening the Health Service Delivery in Crises affected Districts of KP under Public Private Partnershi
p

project was designed to support

the implementation of Comprehensive Development Strategy (CDS)
. The
proposed
project is being
finance
d

under WB
-
MDTF

to the tune of US$ 61 Million
.

Department of Health (DoH) Government of Khyber Pakhtunkhwa (GoKP)

has been
executing

the scheme
.



1.1

Millennium Development Goals (MDGs):

Government of Pakistan has committed to achieve MDGs by the year 2015 with 179 nations on board
.

The MDGs

embod
y

universal
primary education, access to health and drinking water, gender equality and women empowerment,
reducing child mortality and
improving mother health, combating HIV AIDS, Malaria and other diseases and ensuring environmental sustainability and develop
ing
global partnership for development.

The
statistics regarding
health status
in
Pakistan against
the

goals set in
MDGs
are not
promising
as the country
has been
lagging behind

in achieving most of MDGs targets
.

In Khyber Pakhtunkhwa the situation is not very different from
rest
of the country

rather it has deteriorated due to various crises
faced by the province such as
earth quack,
militancy, I
nternally Displaced People (IDPs)
, and catastrophic floods.

The proposed project intends to improve the health status of local populace in the six mili
tancy and floods hit districts of Khyber
Pakhtunkhwa and will contribute to
wards

achieving the MDGs.


1.2

Comprehensive Development Strategy (CDS)
:


The provincial government has approved Comprehensive Development Strategy (CDS) for (2010
-
2017). This strat
egy describes a
path that aims to benefit all the people of the province by offering the possibility of better employment and access to impro
ved
public services involving government, civil society and the private sector.
On the basis of CDS, a health sector strategy has been
prepared.
In this context
the goal of the Department of Health (DoH) is to improve the health status of the population in Khyber
Pakhtunkhwa through ensuring access to a high quality, responsive health
care delivery system which provides acceptable and
affordable services in an equitable manner. Health systems should improve the health status of individuals, families and
communities, defend the population against what threatens its health; protect people

against the financial consequences of ill
-
health; provide equitable access to people
-
centred care and make it possible for people to participate in decisions affecting their
health.


The
proposed project
has been
designed to support implementation
of
heal
th reforms as contained in
CDS
by the Department of
Health (DoH), the Government of K
hyber Pakhtunkhwa
(GoKP), through strengthening the required aspects of provincial level
functions of governance, monitoring and evaluation and planning

to enable
it adequ
ately address the
transition of health functions
in the face of
18
th

constitutional amendment.

1.3

Baseline:
Current health facilities and practice of PPP:

A
s per baseline surveys

majority of rural households are
still
10 or more kilometers
distance away
from
D
istrict Head Quarter
Hospitals (DHQ)
, which means that health services for
expecting mothers

and 24/7 E
mergency
M
edical and
O
peration Care (EMOC)
services are not easily accessible. At present only 50% of women receive any form of ante
-
natal care and

only 25% are receiving any
form of post
-
natal care, from a skilled birth attendant, while only 20% of women are using modern methods of contraception
(sterilization, pill, injection, condom). High fertility rates prove to be a major problem area for the p
rovince. In comparison to other
provinces, Khyber Pakhtunkhwa is lagging behind at a fertility rate of 4.3 with an unmet need of 30.5 % clearly indicating th
e
unavailability of the contraceptives which can, however, be easily resolved. One of the underlyin
g reasons could be overlapping
responsibility between the D
epartment of Health
and the Population Welfare Department
1
.


In Khyber Pakhtunkhwa,
the quality of services was assessed in all districts of the province against approved primary and secondary
health care standards and it was observed that on scale of 1
-
4 the mean resulting score for primary healthcare was 1.8 while at the
secondary care
level it was even worse i.e. 1.3.
To improve the health service delivery, Public Private Partnership has been promoted
in the province. Some of the examples of PPP are entering into management contract with Abasin Health Foundation

(AHF)
, Aga
Khan Health S
ervices

(AKHS)
, Pakistan Red Crescent Society

(PRCS)
, Sarhad Rural Support Program (
SRSP),
People’s Primary Health
Care Initiative (PPHI) and Save the Children Fund (Battagram Model


Hub Approach).





1

Source: Pakistan Demographic Health Survey 2006
-
07

The concept of a hub makes the Rural Health Center
(RHC)

to function as Hub for 8
-
10 Basic Health Units, functions 24/7 and
devolves financial and administrative powers to RHC/Hub manager. At Hubs, all the staff is resident and is provided with
accommodation and some indoor recreational facilities. All the hub
centers are equipped with ambulances for patients requiring
referral to a secondary or tertiary level facility. In addition, medicines and equipment are supplied to the attached B
asic Health Units
(B
HUs
)

from the hub centers.

Third party evaluation
(TPE)
o
f the three year Battagram project conducted in June 2010 has shown
over four times increase in the health facility utilization, improvement in core indicators such as childhood immunization in
creased
from 10% to 76%, Ante
-
Natal Care (ANC) visits from 33%
to 63% and hospital based delivery from 33% to 50%. These results were
achieved against the baseline for which a survey was conducted by Save the Child Fund in consultation with Health Department
(HD)
and World Bank
(WB)
before the initiation of the projec
t in Battagram. The successful innovative approaches, “the hub approach”
and “the performance based incentive” were distinct hallmarks of the project resulting in positive outcomes.

The Battagram Model was declared as highly successful by third party and
earned acknowledgements in government spheres. More
importantly consumer satisfaction level was very high.

Based on the successful experience of revitalizing and improving healthcare
services under a public
-
private
-
partnership
(PPP)
model in Battagram, an
improved version of the Battagram model will be
replicated in selected crises affected districts of the province. The project will ensure the delivery of a comprehensive hea
lth care
package for the district population through a contracting mechanism, wi
th the contractor being given flexibility in management
of health facilities both in terms of staffing and logistics to ensure optimum coverage of the population including adminis
trative
control of the community based and outreach programs, e.g. Lad
y Health Workers (LHWs), Malaria, Expanded Program on
Immunization (EPI), Tuberculosis “Directly Observed Treatment Short course (TB
-
DOTS)”,. The performance of the organization
will be judged against progress on specific, measurable indicators that wi
ll be evaluated regularly.

1.4


Description of Project

Based on the successful experience of revitalizing and improving healthcare services under a public
-
private
-
partnership (PPP) model
in Battagram, the DOH KP intends to launch an improved version of Battagr
am model by replicating those activities in selected crises
affected districts of the province.
The project
titled
as
“Revitalizing and Strengthening the Health Services Delivery in Crisis Affected
Districts in KP through Public Private Partnership” under
the Multi
-
Donor Trust Fund (MDTF). MDTF has been established in Pakistan
to assist the Government of Pakistan in the reconstruction and restoration of basic social services delivery in the crisis
-
affected areas
of Khyber Pakhtunkhwa (KP) and the Federally
Administered Tribal Areas (FATA).

The proposed project will
therefore
involve the
following main activities.


Reconstruction, renovation and repair of health facilities.


During the project, n
ine
completely damaged health facilities will be reconstructed
under the proposed project in Kohistan and D
era
Ismail Khan
Khan districts. While 4
4

health facilities will be renovated and repaired in this project. The reconstruction and repair
process will involve following physical activities.

i)

Site Preparation


Demo
lition of existing damaged buildings and structures or excavation and leveling of land for construction work is likely to aff
ect
the environment negatively. The disposal of demolished materials or debris will be done in a manner to protect the surroundin
g
environment. Minimum use of machinery will be done for excavation, leveling
and

dressing of site to reduce air and dust emissions.

ii)

Designing of buildings


For the designing of building, standard
government
procedure
(SOPs)
and building codes will be follow
ed to ensure construction of
environment friendly
structures
. The structure of buildings will be based on minimum resource consumption and wastes
minimization principles. It would be legal binding on the construction firm(s) to confirm to existing building

codes, abide by seismic
zoning/planning, and plan adequate
,
cost effective sewage and solid waste management before embarking
on
civil works


iii)

Reconstruction Work.


Most of the construction works will be carried out manually, with minimal usage of machine
ry. The exceptions are excavation for
building foundations/boundary wall, for which excavators will be used, small portable concrete mixers, which are used to prep
are
cement concrete mix at the site for all concrete works at the construction sites and sma
ll elevators to lift construction material to
the upper floors. In addition, a small diesel generator may also be arranged at sites where electricity connection is not av
ailable.
Disposal of excavated materials and control of dust emissions during constru
ction work will be taken care of in the mitigation plan.


iv)

Repair and Renovation Work


Subsequent to the construction of buildings, other renovation works including plastering, flooring, fixing of wooden and stee
l
fixtures, toilet fixtures, painting and
polishing works will be carried out. In the existing buildings minor repair work followed by
renovation such as whitewashing, paintings, and polishing works and mitigation measures will be proposed to reduce the
environmental and social impacts.


v)

Installat
ion of Medical Equipments.


Different types of medical equipments and machinery will be installed for providing health care facilities such as X
-
ray machines,
Ultra
-
sound machines, diagnostic equipments, Generators and other allied medical equipments. Sele
ction of environmental friendly
technology will be ensured in the procurement and installation of machines and medical equipments to reduce the overall negat
ive
social and environmental impacts. Using eco
-
friendly breed of medical devices i.e. po
r
table blo
od glucose monitor concept which is
easy to use and cuts environmental impacts by two
-
third, use of steam based instrument sterilization which contains no harmful
chemicals, use of less energy consuming equipments, use of recycled wood or furniture made up

of plastic.


Scope of the Project:


The proposed project would help finance the costs associated with strengthening the health

services affected by the crisis and
militancy in Khyber Pakhtunkhwa and provide the population in the affected districts with
improved access to health care services.
The proposed support will help respond to the situation by improving management as well as availability of services at the pr
imary
care level, and improving the functionality of secondary care hospitals to provide r
eferral services through contracting out
management of the primary health care system. The project will be implemented in six crisis affected districts of KP for a pe
riod of
three years. It is expected that by the end of the project there would be: a) incr
eased utilization and coverage of primary and
secondary health care services in the districts; b) adequately equipped and functional health infrastructure; c) improved sup
ervision
and timely utilization of allocated resources through key management decisio
ns based on evidence; and d) increased community
satisfaction with publicly provided health services.


Based on criteria
i.e.
crisis affected district, poor indicators, other funding available from provincial Annual Development Plan
(ADP)
or developmental
partners
, the project will be implemented in the following six crisis affected districts of KP by Health Sector
Reforms Unit (HSRU
)
:


i)

Battagram (continuation of the previous successful model);

ii)


Buner;

iii)


Lower Dir;

iv)


Dera Ismail Khan;

v)


Kohistan; and,

vi)


Tor Ghar.

1.
5

Project Development Objective:


The development objective of the scheme is to
expand access and availability of quality health care services amongst the affected
population, improve the availability, accessibility and delivery of primary and

secondary healthcare services at the district level, and
to
ensure community satisfaction from public service delivery in the crisis affected districts of Khyber Pakhtunkhwa.


1.
6

Key Results


The project will be implemented in six crisis affected
districts of KP for a period of three years. It is expected that by the end of the
project the following key results will be achieved.


a)

Increased utilization and coverage of Primary Health Care services and secondary care services in the districts,


b)

Adequa
tely equipped and functional health infrastructure,


c)

Improved supervision and timely utilization of allocated resources through key management decisions based on evidence,
and


d)

Increased community satisfaction with publicly provided health care services.


1.
7

Key performance indicators


The key performance indicators include:


i)

People with access to a defined basic package of health, nutrition, or reproductive health services,


ii)

Percentage of children with Severe Acute Malnutrition provided adequate Nutrition

services,


iii)

Births (deliveries) attended by skilled health personnel,


iv)

Contraceptive prevalence rate for modern methods,


v)

Community satisfaction with health care services delivery by public sector


1.
8

Project
Components


The project has
the following three major
components:
-


Revitalizing health care services.


The primary health care centers will be reorganized into hubs and support will be provided to enable delivery of a comprehens
ive
package of health care services. From the first yea
r, management of all facilities in the hubs will be outsourced to a private firm /
non
-
governmental organization (NGO), through a competitive process. The component will finance the contract. The selected firm /
organization will be responsible for a compr
ehensive package of care to the communities through application of the hub approach.
The secondary DHQ hospitals in the project districts will also be improved.


Rehabilitation of Health Infrastructure in the Districts.


Some health facilities

fully or partially

damaged during the crisis will be rehabilitated to enable service delivery. No new facilities will
be constructed and only existing infrastructure will be rehabilitated. The list of facilities will be finalized based on the
resources
av
ailable.


Establish and operationali
z
e a robust monitoring and evaluation system at district and provincial level.


The component will support operationalizing the monitoring and evaluation systems to guide project implementation at the dist
rict
level and
dissemination of the results through province wide analysis. It will also support operationalization of District Health
Information System (DHIS), and periodic third
-
party evaluation of the project in the selected districts including, baseline and endline
surveys to assess results.


Details of
project
a
ctivities


Under component
1

of the

project following activities will be carried out:

Health Se
rvice Delivery at Primary level

In the selected districts, (Lower Dir, Kohistan, Tor Ghar, D
era Ismail Khan,

Buner, and Battagram) assigned number of hubs will be
established in appropriate geographic locations for efficient
service
delivery. Where appropriate the hubs, according to their
geographic locations, will be established at civil hospitals, category D
hospitals or even at THQ hospital. A cluster of BHUs with
financial and administrative control at RHC / category D

/ Civil Hospital will be established meaning a hub.
A RHC hospital or TQH
shall be designated as hub which will comprise of BHUs falling unde
r its localized jurisdiction.
At hub, all the staff is resident
.
A
ccommodation and some indoor recreational facilities

will be provided at the hub
. All the hub centers will be providing 24/7
services equipped with ambulances for patients requiring referral

to a secondary or tertiary level facility. In addition, medicines and
equipment will be supplied to the attached BHUs from the hub centers.

Health Serv
ice Delivery at Secondary level

In the first phase, management of Buner, DHQ Hospital will be contracted

out. Medical Superintendent of the hospital will be
selected through competitive selection amongst the Management Cadre personnel of the Health Department. He
/she

will be
deputed on the strength of the implementing agency and will be accountable as per agreed pre
-
defined roles (agreed by the Health
Department,
DHO

and the Implementing Partner). At the end of the first year the experience will be reviewed and if fea
sible the
management of the rest of the DHQ hospitals will also be outsourced.


Reconstruction, Renovation and Repairs


The health facilities completely destroyed in the crisis will be reconstructed whereas health facilities partially damaged wi
ll be
repai
red and renovated
.
According to the initial statistics about
nine (0
9
)

health facilities completely damaged will be reconstructed
whereas
forty four (
44
)

partially damaged health facilities will be repaired and renovated. Detail list
of health facilities w
hich will be
reconstructed,
renovated or repaired under the project in
four
districts
is
given below:


List of Health Facilities to be Renovated/Repaired in four districts


District/Health Facility

Reported
Damage

Cost

1

District Battagram



21.747



BHU Rashang

Partial

1.16

BHU Paimal Sharif

Partial

0.756

BHU Banna

Partial

12.421

RHC Thakot

Partial

7.410

2

District Dir
-
Lower



20.858



RHC Gulabad

Partial

2.816

BHU Khadagzai

Partial

2.620

BHU Tawda China

Partial

3.088

BHU Nasafa

Partial

2.311

BHU Kakas

Partial

0.756

BHU Utala

Partial

0.790

BHU Asegai (Rabat)

Partial

2.929

List of Health Facilities to be Renovated/Repaired in four districts


District/Health Facility

Reported
Damage

Cost

BHU Sorikandaw

Partial

0.358

CD Koto

Partial

2.165

CD Malakand

Partial

2.366

CD Saddo

Partial

0.274

CD Shahi

Partial

0.386

3

District Kohistan



419.459



BHU Peach Bala

Completely

57.300

BHU Jog

Completely

49.734

BHU Dubair Bala

Completely

49.254

BHU Moni Khail Bella

Completely

51.258

BHU Thoti

Completely

55.2432

BHU Jashoai

Completely

55.9548

RHC Ranolia

Partial

63.1656

BHU Kuz
Paro

Partial

34.5372

BHU Muj Gali

Partial

1.506

BHU Sheryal

Partial

1.506

4

D.I.Khan



105.140



BHU Budh

Partial

3.194

List of Health Facilities to be Renovated/Repaired in four districts


District/Health Facility

Reported
Damage

Cost

BHU Mahra

Partial

5.438

BHU Rashid

Completely

9.345

BHU Jhok Kanera

Partial

2.710

CD Yarik

Completely

10.797

CH Daraban
Kalan

Partial

6.146

RHC Paroa

Partial

14.16

BHU Jabbar Wala

Partial

3.159

BHU Bund Kuri

Partial

3.211

BHU Fateh

Partial

3.866

BHU Gandi Umar Khan

Partial

1.304

BHU Musazai

Partial

2.365

BHU Kot Issa Khan

Partial

1.542

BHU Saggu

Partial

1.322

BHU Takwara

Partial

1.671

BHU Darban Khurd

Partial

6.684

CD Katgarh

Partial

0.584

BHU Malana

Partial

1.192

BHU Maddi

Partial

3.156

CD Diyal

Partial

0.804

`
BHU Mir Bazi

Partial

1.466

BHU Gara Issa Khan

Partial

1.010

BHU Shro Kona

Partial

2.380

List of Health Facilities to be Renovated/Repaired in four districts


District/Health Facility

Reported
Damage

Cost

BHU Roda

Completely

14.474


CD Umar Khel

Partial

0.999

CD Gara Mohabat

Partial

1.662

CD Hathala

Partial

0.499


C
omponent
2

of the project
mainly comprise
s

of the
strengthening and capacity building
activities
of health care provider (HCP)
to
improve

the
quality of health care services through a comprehensive capacity building trainings program. Training
program will be
implemented after
needs assessments to formulate training manuals, materials and tools for th
ese trainings. All trainings will be
imparted through Provincial Health Services Academy (PHSA) or institutions under its administrative control. Payment to PHSA
will
be made by Implementing Agencies.


Component
3

of the project is related to institutional
ization
of
an effective monitoring and evaluation system to facilitate learning
and evidence based decision making at provincial and district level. A Provincial Steering Committee (PSC)
and
Provincial Monitoring
and
Evaluation Committee
(PM&EC)
will be co
nstituted

for overall monitoring

of the project activities

in the six districts and
providing comparisons with in the project districts and with other districts, based on routine reporting mechanisms, reviews
and
evaluation. In addition a third Party will
be
conducted
for validation of data. Also District Health Management Team (DHMT)
comprising of
Deputy Commissioner formerly
District Coordination Officer (DCO),
DHO
, Medical Superintendent (MS) of the DHQH,
District Population Welfare Officer

(DPWO)
, D
istr
ict officer
Finance
and
Planning

(D
O
FP)
, and
two (02)

community leaders will be
notified. The DHMTs will review, monitor and facilitate project implementation at district level.


District Health Information System
will be
integral part of monitoring and evaluation system and disease surveillance
will also be
established
in the project districts

to improve health service delivery
. The D
istrict Health Information System (D
HIS
)

will be used to
provide evidence for decision mak
ing to the various levels of management and oversight as identified above.


1.
9

Project Implementation


The p
roject
will be implemented by
H
ealth Sector Reform Unit (H
SRU
)

of
Health Department, Government of Khyber
Pakhtunkhwa

through public private partnership.

The field activities such as reconstruction, renovation and repair work in health facilities and
health service delivery shall be implemented through private entities which shall be selected by the Health Department

th
rough
competitive bidding process. M
emorandum of Understanding (M
oUs
)

shall be signed with selected entities/firms called as
Implementing Partners (IPs) to carry out health service contracts and delivery of health care facilities to the public. The s
electe
d
entities will establish hubs in suitable places in the districts to provide health care services and referral services to the

communities
in the districts.


The Health Department will advance required budget to the IPs and the IPs shall be responsible to

implement the project activities in
the district including provision of required staff, provision medicines and health care facilities as per agreed terms and co
nditions
between the Health Department and IPs.


District level Implementation.



The field implementation of the project shall be overseen by the
District Health Officer (DHO
)
and their supporting staff in the
respective districts. The
DHO

in addition to his regulatory duties shall
also
be responsible for
the
environmental safeguards

c
ompliance
, management of social safeguards, and performance monitoring of
the
civil works
execution at project sites in the
district. The

DHO

shall also be
responsible for coordination,
supervis
ing
the management contractor
and verification of all
data
pro
vided by the management contractor for onward submission to
P
rovincial Health Department. The
DHO

shall
be the focal person
in the district
to address any grievance/complaints from the community regarding service provision and closely monitor
ing

the
performance of outreach work.


Health Services Contracts


The
project activities will be implemented through
private entities duly registered with the relevant government institution and will
be selected competitively. The D
epartment of Health (DO
H
)

shall
invite
E
xpression of Interest (E
OI
)

in the newspapers
to shortlist
and select suitable private firms/entities

as implementing partners for the project.

Contractual

Agreement will be signed between
the Health Department, Khyber Pakhtunkhwa, implement
ing partner (IP), and the district gove
rnment outlining details
roles and
responsibilities of each partner. The government of Khyber Pakhtunkhwa shall transfer the salary and non salary budget of all

health
facilities to the implementing
partner
.


District

level management of all the vertical programs i
-
e EPI, LHW Program, MNCH, TB D
OTS
,
Roll Back Malaria etc or as planned by the Government will be the responsibility of the Implementing
Partner
.
DHO

of the district will
be responsible for
overall
monitoring
, facilitation and
coordination
and ensure implementation of the policies outlined by the
Provincial Government.

1.
10

Environmental and Social Screening and Assessment Framework



The World Bank has
prepared
an
Environmental and Social Screening and Assessment Framework (ESSAF), in accordance with the
OP 8.0 for emergency operations


applicable to all
projects
financed
under the
MDTF.
It specifies the environmental and social
assessment requiremen
ts that the impl
ementing agencies
will need to fulfill before any
p
roject
is undertaken.
The Framework
describes the generic environmental/social monitoring and reporting requi
rements to be fulfilled during p
roject implementation, in
addition to defining the broad institu
tional arrangements required for environmental and social safeguard
compliance.
The
ESSAF
has been shared with the Government of Khyber Pakhtunkhwa and also disclosed locally. The present ESMP has been prepared in
pursuance of the environmental assessment
requirements defined in the ESSAF.

1.11

Objectives

of ESMP


The
E
nvironmental and
S
ocial
M
anagement
P
lan
(ESMP) provide
s

detailed assessment of
environmental and social impacts of
the
activities undertaken during the
proposed project

and suggests
mitigation measures
,
define the roles and responsibilities of various
stakeholders for implementation and monitoring of the project operations. T
his Environmental and Social Management Plan (ESMP)
has been prepared to achieve the following
specific
objecti
ves:

a.

To address the adverse environmental and social impacts arising from the
reconstruction of damaged health facility(s)

and
refurbishing

/

renovation of various health facilities such as BHUs, RHCs and DHQ Hospitals
under the
proposed
project.

b.

To address the problem of hospital wastes arising from the
project
operation
and
health
care
facilities including BHUs, RHCs,
DHQs
, Hubs

and ensure its safe disposal
ac
cording environmental

standards.

c.

To comply with World Bank Operational
Policy

for enviro
nmental and social safeguards as well as the National Environmental
Laws and Regulations.


1.
1
2

Project Management
Organization


The
proposed
project shall be managed by a Management Unit (MU) headed by a full time Project Coordinator

(PC)
, who will be
responsible for financial management.
Additional Secretary (Development) of Health Department will be co
-
signatory to the project
account.
Health Sector Reform Unit

(HSRU)

will be responsi
ble for technical evaluation
and work
-
plans of the pro
ject. The
Management Unit (MU) will be provided appropriate staff including Finance

and

Admin Officer and Civil Engineer. The capacity of
the MU shall be strengthen by providing short term consultants as and when required for specific task during project
i
mplementation. The MU will function as the Project Secretariat for providing management support to the Project Steering
Committee (PSC). The MU will be responsible for overall coordination, internal/external processing of all approvals, procurem
ent
and imp
lementation of civil works procurement and management of consultant services, operating special account and financial
management. The MU will work under the close supervision of Chief HSRU and Additional Secretary (Dev), Health Department,
Government of Kh
yber Pakhtunkhwa
.

1.
1
3

P
roject Steering Committee (PSC)


Project Steering Committee
(PSC)
headed by the Additional Chief Secreta
ry

(Development)
, Khyber Pakhtunkhwa
will provide overall
strategic management guidance to the

proposed

project
. The PSC has representation from all relevant stakeholders including
Government Departments,
Health
Departments,
IPs
and
Donors
.

The
functions
of PSC are

to:


i)

R
eview progress of the p
roject
,

ii)

S
trategic policy changes in the project
,

iii)

T
o realign the project components with the objectives of the project
as
and whe
n
required
,

and

iv)

A
rbitration, whenever required
.

1.14

Project Management Unit

(PMU)


A project Management Unit (MU) has

been established in
the HSRU, Health Department, Khyber Pakhtunk
hwa
under the
supervision of
a
dedicated Project
Coordinator and management oversight of Chief HSRU. The MU

will be adequately staffed with
professionals and technical specialists including
Admin and Finance, Officer,
Procurement

Specialist, M
onitoring and

Evaluation
(M
&E
)

and Civil Engineer to support the Chief HSRU and Project Coordinator in implementation of the project.

The MU will act as
secretariat of the PSC at provincial level for implementation of the project.


1.15


Management of construction
activities


The reconstruction and refurbishing of partially or completely damaged health facilities will be carried out by a constructio
n firm,
hired by HSRU through a competitive bidding process. The monitoring of the civil works shall be made at two tie
rs: i) at provincial
level by HSRU; and ii) at District / site level by supervisory consultants to be hired for the purpose by HSRU.

1.1
6

District Health Management Team

(DHMT)


D
istrict health management team w
ill be constituted
for oversight, monitoring and
coordinating
/supporting the implementation of
the project in their respective districts. Besides representatives from the line departments at the district level,

the DHMT will have
mandatory

representation of at least two
(02
)
members
from the community.
DHMT meetings will be
chaired by the DC

(formerly
DCO)

and
DHO

would act as secretary for the
DHMT. Preparation and a
pproval of
the district
annual action plan will

be done by
DHMT and
the
DHO

to follow up on the decisions of
the meeting and to put an updated status of these decisions i
n the next meeting
of the DHMT.

1.1
7

Procurements of Contracts



IPs Selection


Several contracts of civil works
will be awarded to the IPs
through a
competitive bidding and selection process
for

the reconstruction
of damaged health facilities in the districts. No I
nternational Competitive Bidding (I
CB
)

contracts are envisaged for civil works in this
project and these contracts shall be awarded on national competitive bidding.
For the management
of health services delivery at
the district level contracts will be awarded to qualified entities

/

firms

/

NGOs
through
competitive bidding process. T
he total
amount of
services
contracts is estimated at US$11.0 million for the six districts. Contracts wi
th
qualified private entities

/

firms will
be procured in accordance with Fixed Budget Selection (FBS).

1.
1
8

Funds Disbursement Mechanism


Disbursement from the grant proceeds, expected in US Dollars, will be translated into Pak Rupees
(PKR)
by the State
Bank of
Pakistan, and the equivalent amount of local currency will be released to the Designated Account (DA) maintained with Nationa
l
Bank of Pakistan

(NBP)
. Disbursements will be made quarterly to

selected IPs
for mana
ging health facilities;
and civil

wo
rk
contractors for rehabilitation of health facilities
.

For payment to
IPs
invoices will be certified by the respective
DHO

as well as
PC /
Chief HSRU. The work of the construction contractors will be supervised by a design and supervision firm who will al
so certify their
invoices before forwarding to the HSRU for payment.

1
.1
9

S
takeholder consultation:


The formulation of ESMP originated from a wider consultation process with the relevant stakeholders. The process has been use
ful
to fetch information and sketch a baseline
for
ensur
ing compliance to environmental and social safeguard at operational level(s
)

through the ESMP
.
The major stakeholders consulted during the process were:
-



1.

HSRU


Health Department

2.

World Bank Islamabad

3.

District Health Officer Buner

4.

Medical Superintendent, DHQ Buner

5.

Law
, Justice and Human Rights
Department

Khyber Pakhtunkhwa

6.

EPA
Khyber Pakhtunkhwa

7.

Civil Society Organizations (CSOs) and Project Affected People (PAPs)


HSRU Health Department, Khyber Pakhtunkhwa

and World Bank
:



Being the executing agency and having
an
in
-
depth understanding of
the proposed
project intervention, HSR
U
provided t
he essential
documents i.e. copies of the WB’s project manual,
P
roject PC
-
I, E
mergency Project Paper (E
PP
)

and allied
documents
which
substantiated the
much needed support in preparation of
the
ESMP.
District health authorities of Buner have be
en consulted while
formulating this ESMP as it was not viable to visit other districts.



The first interaction with the World Bank’s environmental and social safeguard specialist
(s)

team regarding ‘Present Status of
Environmental Safeguards Compliance


progress review meeting
on
the project
proved much useful. The meeting
held at Serena
Business Center Islamabad on 29
-
30 January, 2013.
It
provided an in depth acquaintance to the WB
’s sponsored

projects,
stakeholder
s
, and work initiated under different E
SMPs. It was
productive
as the basic
precondition
for formulation of
health sector
ESMP project vis
-
à
-
vis compliance to Hospital Waste Management Rules
(HWMR)


2005 as guideline
was discussed.

In reality, the
rule provides a road map for hospital waste ma
nagement across the country if addressed in
its
letter and spirit.


During these consultations the
proposed institutional arrangement at provincial, district and facility levels and insight on internal
monitoring of
the
scheme
have also been discussed in d
etail.
The provincial level monitoring will be carried out by HSRU on
quarterly basis. While the District Health Officer concerned and his team comprising of Deputy District Health Officer
(DDHO)
and
Coordinator Public Health
(CPH)
will conduct monitoring
of planned activities on regular basis and progress report of it will be
submitted to HSRU.


District Health Officer
and Medical Superintendent
District
Buner
:


During the discourse DHO Buner was optimistic about the proposed project interventions as it would be
a desirable
support
in
rehabilitation of
physical damages occurred to health establishments (complete or partial) in the district. According to
DHO

almost

all health
infrastructures

have been partially or completely damaged

due to floods and ongoing militancy.
For example BHUs at
Bagh, Topi and Dhok Adda, RHC Gul Bandi etc. have completely been damaged
. Similarly, in the wake of security situation most of
h
ealth facilities are presently been occupied by law enforcement agencies. However, the O
ut Patient Department (O
PD
)

remain
functional, albeit, patient turn out, especially women folks, has drastically been declined due
to
numerous reasons i.e. observance o
f
purdah and prevailing social norms. Resultantly, the emergency care at DHQ
and THQ
Buner has been increased many fold

especially
in case of emergency
while various
ailments
amongst

children and women has increased due to limited
opportunities available
to
them

at door step
. Besides, maximum utilization of petite sanitation, water supply, and residential facilities
by both law enforcement
agencies

and paramedical staff
ha
s
too been damaged
and requires early rehabilitation. He was certain that the project

is useful and
through reconstruction of health facilities effectiveness of health governance along with health indicators be enhanced.


With regard to environmental aspects of hospital waste and level of awareness amongst the paramedical staff and general

public,
the officer apprised that
numerous
NGOs have been supportive during the last three years as awareness trainings on health and
hygiene, sanitation
,
safe disposal of waste and keeping
the
surroundings clean and healthy were organized by them. Howeve
r,
resource mobilization has been a

factor

which hindered health facilities with no proper collection, handling, storage, transportation,
disposal

system
or incineration. The collected waste is just burnt in a pit dig in corner of hospital premises which i
s also a reason for
contamination of sub
-
surface water. The waste
which is burnt in the pit
also includes infect
ious

bio
-
medical
waste
. The same
requires special handling and incineration at high temperature to minimize its impacts on health and environs.
The DHO proposes
following recommendations for the effectiveness of health governance and to restore trust of local communities:
-


i)

Early reconstruction
and rehabilitation
of completely or partially damaged health facilities to ensure health governance at
d
oor steps to
a
ffected population;

ii)

Provision of life saving drugs

and up to date medical equipments

in affected hospitals
;

iii)

Provision of additional medical and paramedical staff especially female

staff
;

iv)

Safe sanitation facilities i.e.
incinerator

with allied trained staff and required O&M;

v)

Strengthening of waste collection, segregation, storage, transportation and safe disposal system
and equipments
at
tertiary level hospitals;

vi)

Capacity building trainings on
Hospital Waste Management Rules (HW
MR
)

-

2005, preparation and implementation of
WMP on regular basis.


E
nvironmental
P
rotection Agency
Khyber Pakhtunkhwa

(E
PA
-
KP)
:


EPA
-
KP was consulted to ascertain status of
the Pakistan Environmental protection ACT (
PEPA
)

-

1997 and allied rule, regulations,
standards there under in the wake of 18
th

Constitutional amendment. It was conveyed that a
ccording to
Initial Environmental
Examination (IEE)
/
E
nvironmental Impact Assessment (E
IA
)

Regulations


2000
,

establishment of

new
public facilities with significant
off
-
site impacts e.g. hospital wastes, require submission of Initial
IEE
report. The applicability of these regulations to the above
mentioned activities is not relevant because no new hospital construction is involv
ed and scope of this project is limited to repair,
renovation and reconstruction of the existing health facilities. Therefore, preparation and submission of IEE or EIA to conce
rned
agency for grant of
environmental approval /
N
o Objection Certificate (N
OC
)

is not required. However, operation of these health
care facilities is likely to create hospital wastes disposal problems and the projects shall have to comply with Hospital Was
tes
Management Regulations
-

2005 (HWMR) and the National Environmental Qualit
y Standards (NEQS) of Pakistan.
However, the
agency has formulated a new
Khyber Pakhtunkhwa Environmental Protection Act


2013. The
Law Department has vetted the draft
and communicated its concurrence. The act is
under final scrutiny and submission to rel
evant forum for approval
. When
promulgated,

PEPA
-
1997, HWMR
-

2005 and NEQS

will be repealed and new rules and regulations would be in place
.


Department of Law, Justice and Human Rights for Implications of
18
th

Constitutional Amendment on aforesaid Acts / Laws:


The
Department of Law, Justice and Human Rights

was consulted w
ith regard to implications of 18
th

Constitutional Amendment on
Acts / Laws and Rules

mentioned in the ESMP. The department conveyed that

exi
sting federal
Laws
,
Acts
, and
Rules
are protected
under the Constitution of the Islamic Republic of Pakistan’s Article

270
-
AA (sub
-
clause
-
6) on ‘Declaration and continuance of laws
etc. The same is reproduced below:
-


Article


270
-

AA (Sub
-
Clause
-

06):

Notwithstanding omission of the Concurrent Legislative List by the Constitution (Eighteenth
Amendment) Act, 2010, all laws with respect, to any of the matters enumerated in the said List (including Ordinances, Orders,

rules,
bye
-
laws, regulations and noti
fications and other legal instruments having the force of law) in force in Pakistan or any part thereof,
or having extra
-
territorial operation, immediately before the commencement of the Constitution (Eighteenth Amendment) Act, 2010,
shall continue to rema
in in force until altered, repealed or amended by the competent authority
2
.
Consultation with
NGOs /
CSOs and
Project Affected People (PAPs)
:


The proposed project envisage
s

revitalizing of health care services through a PPP approach.
As the
management of a
ll health
facilities in a hub will be outsourced to a private firm, an NGO,

or
CSO through a competitive process
, t
herefore all

a list of all
leading NGOs / CSOs active in the project area regarding their health care initiatives (especially in Malakand
and Buner)

has been
complied
.

The same is as follows:
-




Plan to conduct to conduct consultations during implementation of the project:


In order to ensure effective and meaning full implementation of ESMP, the document will be
shared with all the six (0
6) District
Health Management Teams (DHMTs)
. Further in collaboration with the each District Social Welfare office a consultation process will
be held with relevant NGOs / CSOs and project affected people (PAPs) in the first quarter of the proposed project

implementation.
The ESS and DHO will be entrusted the task of consultation and reporting to the HSRU. The representatives of NGOs / CSOs and
progressive PAPs will also invited in the capacity building workshops as proposed in the ESMP and be conducted by
ESS and HSRU.






2

Source: Constitution of the Islamic Republic of Pakistan as modified up to the 30
th

April, 2010 provided by Department of Law, Justice and Human Rights,
Govt. of Khyber Pakhtunkhwa, Peshawar.

CHAPTER


2:

REVIEW OF
POLICIES AND
LEGISLATIONS

The Environmental and Social Management Plan has been developed after reviewing all the relevant env
ironmental and social
safeguard

legislation and guidelines of
the
Government of
Pakistan
and the World Bank

Operational Policies (O
P
s) applicable to this

project.
A brief description of th
ese

policies and
legislations, and their relevance to the proposed project

activities
, are
given
below.

2.1

Pakistan Environmental Protection Act, 1997


The
Pakistan Environmental Protection Act (PEPA), 1997
empower

the government to frame regulations for
environment protection
and pollution control
.
S
ection 12 of this Act requires that every proponent of the project shall submit an
Initial Environmental
Examination
(IEE) or an
Environmental Impact Assessment
(EIA) before
commencement of
construction and operation of any
new
project

which is likely to cause adverse environmental effects.
Section 11 of Pakistan Environmental Protection

(PEPA, 1997)
prohibit
the

discharge or emission of any effluent or waste
s
to environment
including hospital waste

or air pollutant or noise in an amount,
concentration or level which is in excess of the National Environmental Quality Standards
(NEQS)
of P
ak
istan. Hence, PEPA, 1997 is
the
major environmental law applicable to
this project as it involves
both re
construction of
health facilities and also operation of
these facilities are likely to produce hospital wastes which need to be taken care of in
accordance with the law

and NEQS
.


However,
as per statement of
EPA
KP,
in response to
18
th

Constitutional amendment
the concurrent list has been abolished and
functions inter
-
alia, with regard to the subject of ‘Environment And Ecology’ have been devolved

to the provinces.
Consequently,
using PEPA
-
1997 as baseline,
the Khyber Pakhtunkhwa Environmental Protection Act


2013 has been formulated. The act is under
final submission to appropriate forum(s) for their consideration and approval
.
PEPA


1997
, as per Article 270
-
AA (sub
-
clause
-
06) of
the constitutions,
has legally been intact till the promulgation of new act
.

2.1.1

Environmental Protection Agency (Review of IEE/
EIA
)
Regulations, 2000


The
Pakistan Environmental Protection Agency (Review of IEE

& EIA) Regulations 2000
define the procedures for categorization,
preparation, review and approval of environmental assessments

reports of all developmental projects. Under these regulations
p
rojects have been categorized into Schedule I and Schedule II
d
epending upon the nature and scale of environmental impacts.
P
rojects included in Schedule
-
I require initial environmental examination, whereas those included in Schedule
-
II require full scale
environmental impact assessment.

According to IEE / EIA Regulations
-

2000 establishment of new
public facilities with significant
off
-
site impacts e.g. hospital wastes require submission of Initial Environmental Examination (IEE) report. The applicability of
these
regulations to the abov
e mentioned activities is not relevant because no new hospital construction is involved and the scope of this
project is limited to repair and reconstruction of the existing health facilities. Therefore, no IEE or EIA is required. Howe
ver, the
operations o
f these health care facilities are likely to create hospital wastes disposal problems and the projects shall have to comply
with Hospital Wastes Management Regulations
-

2005 and the National Environmental Quality Standards (NEQS) of Pakistan.

Nevertheless
,
in the wake of 18
th

constitutional amendment, and promulgation of
Khyber Pakhtunkhwa Environmental Protection
Act


2013, the IEE / EIA Regulations


2000 shall be revised.

2.1.2


Hospital Wastes Management Rules
(HMR)
2005


The
HWMR
-

2005
are binding on
every hospital

/

health facility
for proper
collection and
management of waste generated by it till
its final
dispos
al

in accordance with the provision of the
PEPA


1997 and NEQS
.

For this purpose the
Medical Superintendent (MS)
or in
-
charg
e
of a health care facility will

constitute a waste management team
(WMT)
and prepare a proper
Waste Management
Plan

(WM
P
)
.

In response to the 18
th

constitutional amendment, a corresponding set of provincial Rules will be formulated by the
GoKP.


Waste
Management Team (WMT)
:


A

WMT shall be responsible for the preparation,
monitoring, periodic review, revision, or updating, if necessary, and implementation
of the Waste Management Plan (WMP), and for supervision of all actions taken in compliance with the

provision of the rules.

Meetings of WMT may be held at least twice a month for which purpose one
-
third attendance of its members required as per rule
s
.
The composition of WMT is as follows:
-


(a)

Medical Superintendent





Chairman

(b)

Heads of all hospital depar
tments




Member

(c)

Infection Control Officer





Member

(d)

Chief Pharmacist






Member

(e)

Radiology Officer






Member

(f)

Senior Matron







Member

(g)

Head of Administration





Member

(h)

Hospital Engineer






Member

(i)

Head of sanitation staff





Member

(j)

Other hospital
staff members as MS may designate


Member

(k)

A public rep
resentative
of District Administration


Member

nominated by

the
D
eputy Commissioner

(formerly D
istrict Coordination Officer)

(l)

A rep
resentative
of Provincial Agency concerned


Member


Roles and
responsibilities of MS:


The rules specifies in detail roles and responsibility(s) of each member of the WMT. However,
the
duties and responsibilities of MS
are reproduced below:
-


(a)

Constitute the WMT;

(b)

Designate the Waste Management Officer (WMO)
;

(c)

Facilitat
e meetings of the WMT and ensure implementation of its decision;

(d)

Supervise implementation, monitoring and review of the WMP and ensure that it is kept update;

(e)

Arrange for a waste audit of the hospital by an external agency as may be designated for the purp
oses by the Government,
involving analysis for the existing waste stream and assessment of existing waste management practices;

(f)

Allocate sufficient financial and
manpower resources to ensure efficient and effective implementation of the WMP; and

(g)

Ensure
training and refresher courses for the concerned hospital staff