E1855 rev.
2
CAMBODIA: SECOND HEALTH SECTOR SUPPORT PROGRAM
UPDATED
Environmental Management plan
Prepared forEast Asia Human Development Sector Unit
The World Bank
1818 H Street N.W.
Washington, D.C., USA 20433
Prepared by
MINISTRY OF HEALTH
Royal Government of Cambodia
1.0 Introduction
1. The Ministry of Health with support from the EVS Environment Consultants (EVS) undertook an environmental review (ER) of the Cambodia Health Sector Support Project (HSSP) during its preparation, which included an environment management plan (EMP). As part of the preparation of the Cambodia Second Health Sector Support Program (HSSP2), the ER was reviewed to assess its relevance, and the performance and implementation experience of implementing the EMP. The ER documents Cambodia’s environmental laws, regulations, policies and other relevant legislation to ensure that applicable environmental assessment requirements are fully addressed during project implementation.
2. This ER assesses potential environmental and human health impacts of the planned project, particularly with regard to: (a) construction and rehabilitation of health care facilities (HCF) focusing on operational health care waste management (HCWM) practices, incinerator use, arsenic in groundwater, and extraction of asbestos when present during civil works; and (b) pesticide use in malaria and dengue vector control programs. Environmental issues relevant to these HSSP2 activities are detailed in the body of the report. Recommendations are made as to appropriate mitigation measures and monitoring programs to be followed with a view to guiding project design and incorporating appropriate management plans during HSSP2 implementation.
1.1 Program Description
3. The World Bank support to the second phase of health sector support program (HSSP2) will contribute to the country level sector pool along with DFID, AusAID and UNFPA with the expectation of more partners joining at a later stage. The pool will also facilitate harmonized management arrangements for support by non-pooling partners through discrete accounts in the Ministry of Health.
4. HSSP2's development objective is to support the RGC Health Strategic Plan strategies to improve access to, and utilization of effective, efficient and quality health services to improve the health status of the Cambodia population by (a) strengthening primary health care and essential referral services, (b) strengthening health financing and social protection mechanisms for the poor; and (c) strengthening human resources and institutional capacity on the Ministry of Health.
1.2 Program components
5. The four program components are aligned with the HSP2 strategic areas. Activities supported under different components are subject to the Government’s 3-year and Annual Operational Planning processes.
Component A: Strengthening Health Service Delivery
6. This component will support the consolidated and integrated delivery of essential health services in health centers (Minimum Package of Activities – MPA) and referral hospitals (Comprehensive Package of Activities – CPA) through (a) the provision of Service Delivery Grants (SDGs) and (b) investments for the improvement, replacement, and extension of the health service delivery network.
Component B: Improving Health Financing
7. This component is aligned with the HSP2 health financing strategy that calls for continued policy and advocacy work, further review and development of the Strategic Framework of Health Financing 2008, and the implementation of social protection measures to protect people from catastrophic out-of-pocket health costs. This component will finance (a) Health Protection for the poor through Health Equity Fund arrangements; and (b) support the development of health financing policies and institutional reforms.
Component C: Strengthening Human Resources (HR)
8. A major bottleneck to improving service delivery outcomes in Cambodia is HR, including (a) staff shortages (e.g. midwives); (b) poor performance incentives; (c) inadequate skills and competencies; and (d) difficulties in recruiting and retaining staff in remote rural areas. Performance contracting described under Component A, improved management of user fee income, and institutional reforms driven by the Council of Administrative Reform, will support improving the incentive package at front line health facilities. This component will focus on (a) strengthening pre- and in-service training, (b) strengthening human resource management in the MOH, and (c) the Merit Based Performance Incentive scheme for health managers and key technical staff participating in the implementation of the HSP2 at central and provincial levels.
Component D: Strengthening Health System Governance
9. This component will support to the MOH shift from a hierarchical administration of health services towards a policy, regulatory and oversight institution. As the implementation of HSP2 moves forward, Program support will be available for (a) developing a priority set of policy packages identified in the HSP2; (b) strengthening the institutional arrangements at all levels of the health system – national, provincial, and operating districts, including a leadership and management training program; (c) private sector regulation and partnerships; and (d) supporting governance and stewardship functions of the national programs and centers overseeing the three HSP2 strategic programs.
2.0 environmental assessment
2.1 Civil Works
2.1.1 Health Facility Construction and Rehabilitation
10. Similar to HSSP, civil works are expected not to cause adverse impacts to the environment and people. Most of the HCFs to be supported are health centers with support for the rehabilitation/renovation of a few hospitals. Review of the preliminary design models for referral hospitals and health centers indicates that construction and/or renovation will not trigger an environmental assessment under the Ministry of Environment EIA guidelines (new full service referral hospitals , i.e., inpatients, outpatients, surgery, x-ray, laboratory, emergency, ambulance, patient wards, maternity, blood bank, pharmacy, janitorial, kitchens, administration, are expected to have a total floor space of approximately 2,000 m2 which is well within the 8,000 m2 size threshold for new buildings requiring assessment). Building height is not expected to exceed 6 m; again well within the 12 m height threshold. Similarly, design models for health centers – both outpatients and combined outpatients and inpatients – provide for modest sized buildings with a maximum floor space of 110 m2 and a height not exceeding 6 m.
11. Although environmental assessment is not required for HCF construction and rehabilitation, as was the case for HSSP, best practices will be followed to preempt any potential human health and environmental impacts. Particular attention will be given to the design of hospitals and health centers by including in the construction basic facilities such as water supply, incinerator and wastewater treatment system. Also, particular attention will be given to the proper handling and disposal of hazardous building materials such as asbestos that may be present at facilities undergoing rehabilitation.
12. Asbestos, a fibre mined in several countries, has been widely used worldwide as a construction material and insulator because of its strength, durability and heat resistance characteristics. In recent years, evidence on the adverse health effects of exposure to asbestos has been mounting globally leading to urgent calls to cease production of the most-harmful asbestos types, limit the use of less-harmful asbestos (e.g., discontinued spraying of asbestos), and to impose strict exposure standards for workers handing raw asbestos and asbestos-containing products. Occupational exposure to asbestos by inhalation can cause asbestosis (scarring of the lung tissue), lung cancer, and mesothelioma (cancer of the lung’s lining). In developed countries, occupational asbestos exposure is thought to have peaked in the 1970’s but the effects of exposure continue to manifest themselves today with an estimated 30,000 new asbestos-related cancers being diagnosed every year.
13. The surge of asbestos use in developing countries as they increasingly industrialize has raised concerns of a second epidemic of asbestos-related cancer deaths over the next three decades. Although the use of asbestos has fallen in developed countries, it has climbed dramatically in developing countries in the past twenty years. For example, asbestos consumption in Thailand rose from 21,271 metric tons in 1970 to 164,000 metric tons in 1994. In Thailand, asbestos is used extensively in the manufacture of construction materials such as roofing, flat sheets for wall and water pipes – these fibre cement products typically contain 13% asbestos by weight. Demand for asbestos building materials is expected to remain high in developing countries due to their low cost compared to alternatives such as polyvinyl chloride (PVC) plastics and galvanized metal.
14. Occupational health risks posed by asbestos in Cambodia are difficult to assess because of limited information concerning the use of asbestos building materials. Consultations with the SFKC, who are responsible for government civil works in Cambodia, suggest that asbestos may be present in existing building containing fibre cement products. While clay roofing tiles are the preferred roofing material used in provincial and district HCF, fibre-containing ceiling sheeting is a commonly used building material in Cambodia. Since 2000, the SFKC have specified that asbestos-fibre concrete building materials are no longer permissible – construction is closely supervised to ensure that contractors do not use cheap asbestos materials manufactured in Thailand. Recommended follow up actions detailed in the Environmental Management Plan include surveying HCF to be rehabilitated as part of the HSSP2 in order to quantify the risk posed by asbestos that may be present in existing structures and to determine appropriate occupation health and environmental mitigation measures.
15. Clearance and preparation of sites may be required since in many areas there was an existing HCF. Therefore hazardous waste from the facility may exist. This waste would have to be cleaned before the construction starts. Also appropriate disposal for this waste must be carried out.
2.1.3 Drinking Water Quality
16. Considerations relating to ensuring the supply of safe drinking water to new and rehabilitated HCF are outlined in this section. Particular attention is given to potential risks associated with arsenic in groundwater and microbial water quality.
Arsenic
17. The potential for naturally occurring arsenic to appear in groundwater was identified as a concern in connection with provision of safe water supply to HCF. In recent years, it has become increasingly apparent that drinking water guidelines are quite frequently exceeded in available water sources worldwide. Arsenic is now recognized as one of the most serious inorganic contaminants in drinking water on a global basis (UN/WHO, 2001). The most serious groundwater problem identified to date has been in Bangladesh where very high arsenic levels in groundwater affects drinking water wells. The heavy reliance on groundwater for public drinking water supply in Bangladesh has resulted in an estimated 40 million people having been exposure to high arsenic levels. Consumption of elevated levels of arsenic in drinking water over long periods of time has been associated with a variety of human health problems including skin disorders and respiratory, cardiovascular, immune, reproductive, gastrointestinal and nervous system ailments.
18. Both surface and groundwater are used as sources of drinking water in Cambodia. Although surface water quality in generally very high and is the preferred source of drinking water, an estimated 50% of the country’s population currently uses groundwater. A recently completed water quality study indicated that groundwater from certain areas of the country contains levels of arsenic that could pose problems for human health (Feldman, 2001). Arsenic levels measured are summarized by province in Table 1 (Note: Phnom Penh was not included in the study area). These values represent the highest or ‘worst case’ arsenic levels measured for individual wells in each province – spatial variability for arsenic is typically high and it is not unusual to get widely different measurements even for wells located in the same village. Study results reveal that several water sources, in both urban and rural locations, were found to contain arsenic concentrations above WHO’s recommended limit of 10 µg/l (WHO, 1993). The highest arsenic concentrations were detected in Kandal Province. Elevated levels were also detected at sampling locations in Kracheh, Svay Rieng, Kampong Thum and Bat Dambang provinces.
Table 1 Overview of groundwater arsenic levels in Cambodia.
Province / Arsenic Concentration (µg/l)Banteay Mean Chey / < 10
Bat Dambang / 50
Kampong Cham / < 10
Kampong Chhnang / < 10
Kampong Speue / < 10
Kampong Thum / 10 - 50
Kampot / No Data
Kandal / 100
Kaoh Kong / No Data
Kracheh / 100
Krong Kaeb / No Data
Krong Pailin / No Data
Krong Preah Sihanouk / No Data
Mondol Kiri / No Data
Otdar Mean Chey / No Data
Pousat / < 10
Preah Vihear / No Data
Prey Veaeng / < 10
Rotanak Kiri / No Data
Siem Reab / < 10
Stueng Traeng / No Data
Svay Rieng / 10 - 50
Takaev / < 10
19. It is noted that monitoring of arsenic in groundwater has not yet been completed in all twelve provinces (i.e., indicated by shading in Table 1) targeted by the HSSP; no data is currently available for six of these twelve provinces. Feldman’s (2001) study covered only thirteen Cambodian provinces and municipalities due to budget and time constraints. Follow up sampling completed by the WHO and UNICEF subsequently included Stueng Traeng Province and increased the number of wells sampled – groundwater arsenic in Stueng Traeng was found to exceed 10 µg/l. JICA have also completed extensive sampling of villages in Central and Southern Cambodia. Although these studies augment the spatial coverage of groundwater arsenic surveys in Cambodia some data gaps remain in the HSSP provinces. Specifically, limited or no data is presently available for Kampot, Koah Kong, Krong Kaeb, Krong Pailin, Otdar Mean Chey, and Preah Vihear. Of these provinces, it is likely that low arsenic levels are prevalent in Kampot and Krong Keab (P. Feldman, Personal Communication). The surficial geology of Cambodia is dominated by the Mekong and Tonle Sap river systems. Study results suggest that elevated arsenic levels are closely correlated with alluvial sediments (i.e., river deposits). Lower groundwater arsenic levels have been measured in the southeastern, southwestern, and northeastern provinces where bedrock lies closer to the surface. Extrapolating from available geological and groundwater survey data suggests that groundwater arsenic may be elevated in Krong Pailin and Preah Vihear, with lower levels likely in Otdar Mean Chey (P. Feldman, Personal Communication).
20. There are currently no standards or regulations concerning drinking water quality in Cambodia; although it was learned that the Ministry of Industry, Mines and Energy (MIME) are in the process of developing guidelines. In the absence of national guidelines, WHO guidelines values can be used to evaluate the potential human health impacts of drinking water sources. It is important to note that the WHO guidelines are not intended as standards but instead as guidance values in interpreting data. In reviewing survey results, it should be recognized that the WHO’s provisional guideline for arsenic of 10 µg/l may not be practical for many developing countries to achieve. For this reason, an action level of 50 µg/l has been proposed by UNICEF in Cambodia. The provisional WHO guideline of 10 µg/l is considered appropriate for a long-term goal but may be overly stringent in the near term given the difficulty of measuring trace arsenic and the expense of treatment at such low levels. Instead an interim standard of 50 µg/l is recommended – this represents the current drinking water standard in most countries. Further, a tiered-system of categorizing risk is suggested where: (i) no actions are necessary when arsenic concentrations are < 10 µg/l; (ii) arsenic concentrations of 10 – 50 µg/l are ranked as a medium priority triggering additional testing to assess the geographical extent of the problem and periodic monitoring to assess temporal changes; and (iii) arsenic concentrations 50 µg/l are a high priority requiring treatment of affected drinking water or substitution of alternative water sources.