World Bank Document · PDF fileOrganisational structure ... Environment Training Needs Assessment (ETNA) study .47 * iii. ... Final Report Karnataka Health,

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* ~~PROPOSED KARNATAKA HEALTH SYSTEMSDEVELOPMENT AND REFORMS PROJECT

* _____ _____ ______E1 078

*~~ Final Report

* ~Environment Management Plan

* ~~~~~January 2005

* Prepared with support from

Shashwath*Prtekh# 16/2-13, Near Gym

* Behind Vijaya Enclave, KodichikkanahalliBangalore 560 076

* -Website shashwath.orge-mail: inho'xhdshwdLhwa.orS!

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* Ii ~~~~~~~~~~~~~~~~Prepared and submnitted by

t ~~~~~~Karnataka Health Systems Development Project0 ~~~~~~~~~Government of Karnataka

t ~~~~~~~~~1St Floor, Public Health Institute Building

Sheshadiri Road* Bangalore - 560 001

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List of Acronyms:

* AD Auto Disable SyringeAPCA Air Pollution Control AreaBMWM Bio-Medical Waste ManagementBPL Below Poverty LevelCHC Community Health Centre

* DHO District Health OfficeDNEO Deputy Nodal Environmental Officer

* DoHFW Department of Health & Family WelfareEA Environment Assessment

* EMP Environment Management PlanHCWM Health Care Waste ManagementHRD Human Resources Development

* ICF Infrastructure Challenge FundIEC Information Education & Communication

* KHNPP Karnataka Health Nutrition Population Project (now changed to KHSDRP)KHNPP Karnataka Health, Nutrition & Population Project

* (KHSDP Karnataka Health Systems Development ProjectKHSDRP Karnataka Health Systems Development Reform Project

* KSIHP Karnataka State Integrated Health PolicyKSPCB Karnataka State Pollution Control BoardNGO Non Governmental Organisation

* NSS National Sample SurveyODS Ozone Depleting Substances

* PH Fund Public Health FundPHC Primary Health Centre

* PHS Primary Health ServicesPHU Primary Health Unit

* PPC Puncture Proof ContainersPRI Panchayat Raj InstitutionsRCH Reproductive and Child Health

* RMP Registered Medical PractitionerSC Sub-centre

* SC/ST Scheduled Caste / Scheduled TribeSIP Service Improvement Plan

* SNOE State Nodal Officer EnvironmentSPCB State Pollution Control Board

* TB TuberculosisTOR Terms of ReferenceTOT Training of Trainers

* UPS Uninterrupted Power SupplyWEEE Waste from Electrical & Electronic Equipment

* ZP Zilla Panchayat

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* List of Contents

1. Introduction .......................................................... 12. Management Measures ................. ...................................... 2

* 3. Best Practices ....................................................... 53.1 Drug Redistribution Practise ....................................................... 5

* 3.2 Landscaping and gardening ....................................................... 53.3 Repairs ....................................................... 5

* 4. Organisational structure ....................................................... 65. Training & Capacity Building Plan ....................................................... 9

* 5.1 Target groups for environmental training .............................................. 9* 5.2 Training calendar for one year ....................................................... 11

5.3 Formulation of Training Policy ....................................................... 13* 5.4 Draft Training Policy ..................... .................................... 13

6. Communication Plan ........................................................ 14 l* 6.1 Environmental declaration ........................................................ 14

6.2 Distribution list ........................................................ 14* 6.3 Regular meetirgs with support institutions . 14

6.4 Environmental Management Information Board .146.5 Complaint Phone Number with centre in DHO .14

* 6.6 Rewards & Recognition mechanism for environmental compliance .146.7 Joint environmental programmes with KSPCB .146.8 Records........................................................R.15

7. Proposed Consultative Process & Disclosure Plan .16* 7.1 Stages of Consultative Process .16

7.2 Specific mechanism for community involvement .16* 7.3 Public Disclosure of EMP .17

8. Monitoring Plan........................................................Mo.188.1 Internal audit.........................................................18

| g 8.2 External audit .188.3 Gram Sabha.........................................................18

* 9. Budgetary Provisions .19APPENDICES .................................... .. 23

* A. Planning and design stage guidelines .24i. Environmental Checklist for the ICF Proposal Review Committee .24ii. Guidelines for incorporation environmental aspects into Service

* Improvement Plan (SIP) . . .26iii. Environmental Guidelines for siting of a PHC/PHU/SC .26

v iv. Land-related Guidelines for siting of a PHC/PHU/SC .28v. Planning and Design criteria for building and infrastructure guidelines 30

* vi. Water supply system planning guidelines .32vi. Water supply system planning guidelines .32

* vii. Sewerage system planning guidelines .33viii. Electrical infrastructure planning guidelines .36ix. Ventilation requirement guidelines .37

* x. Vehicular parking infrastructure guidelines .37xi. Landscaping guidelines .37

* xii. Noise reduction guidelines. 38B. Construction stage Guidelines .40

* i. Debris & Dust control .40C. Operation stage Guidelines .40

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* ii. Water supply maintenance guidelines .............................................. 40iii. Sewerage system maintenance guidelines .......................................... 40

* iv. Guidelines for managing waste in electrical and electronic equipment (WEEE)41

* v. Vehicle maintenance .............................................. 41vi. Measures for managing environmental impacts of camps ...................... 41vii. Guidelines for Bio-medical waste management including housekeeping within

* a PHC/PHU/SC .. 42viii. Guidelines for disposal of bio-medical wastes in a PHC/PHU/SC .43

* ix. Guidelines for disposal of placenta in a PHC/PHU/SC .43x. Guidelines on the use and disposal of sharps in a PHC/PHU/SC .44

* xi. Terms of reference for the periodic internal and external environmental* monitoring review .. 45

xii. Other environmental monitoring activities for a PHC ............................ 45i xiii. PMP with regards to DDT usage in the institutions ............................... 46

xiv. List of references for Planning and Construction .................................. 46* D. Listof special studies ........................................... 46

i. Pesticides and ODS in Health Programmes (current status & project* interventions) with emphasis on DDT .. 46

ii. Environment Training Needs Assessment (ETNA) study .47* iii. Adequacy and Need Assessment of Infrastructure for Environmental* Management .. 47

* List of Tables

Table - 1: Management measure. 2* Table - 2 Roles and responsibilities of various levels of officials involved in KHNPP for

EMP.7Table - 3 Model log for inventorisation of BMW .15

* Table - 4 Stages of consultations in EMP suggested for the project .16Table - 5: Monitoring measure .18

* Table - 6 Budget for EMP .19Table - 7 Budget for Civil Works .21

* Table - 8 Evaluation Matrix for funding proposal under ICF .24Table - 9Provision of set backs from electric lines .31Table - 10 Format for controlling of cleaning of water tanks. 40

v Table - 11 Format for controlling of de-sludging of septic tanks ........................... 40Table - 12 Format for vehicle maintenance .41

0List of figures

Figure - 1 Organisational structure for EMP. 6* Figure - 2 Siting and Locational criteria .28

Figure - 3 Decentralised Waste Water Treatment System for PHC/PHU .35

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Final Report Karnataka Health, Nutrition & Population Project (KHNPP)

* 1. Introduction

* The incorporation of environmental concerns during planning, designing,* implementation and monitoring stages by formulating Environmental Management

Guidelines will serve to enhance positive impacts and mitigate negative impacts in* the development of the proposed project activities. The guidelines are the outcome of

the assessment of the natural resources of the region, possible project components* as well as consultations. This section/part suggests appropriate

mitigation/management measures to minimize the risks perceived in the* Environment Assessment (EA) part. It also outlines monitoring indicators for various

activities and monitoring plan.

* The Guidelines provided along with other environmental management measures,would be incorporated during the implementation stage. Besides, this section also

* contains some of the existing best practices in the Primary Health Care Services.Although these practices are not uniform, it is highlighted in this chapter in order to

* ensure that it is adopted uniformly throughout the state of Karnataka.

* Although a well established organisational structure is proposed for the overall* project management, in-order to provide better focus on the environmental aspects

in the project, an organisational structure with individual roles and responsibilities to* execute the EMP is given.

* A project is successful only if all the stakeholders are aware of the managementmeasures to be adopted and the reason for executing each of the activities. They

* should also be apprised of their roles and responsibilities in the project. Thus trainingand capacity building component in the project is a must. This section includes sucha chapter which not only gives the target groups, but also gives a tentative training

* schedule and policy to be adopted during implementation.

* For effective communication of the guidelines and management measures, a plan ismade. This communication plan lists out the areas and the responsibilities and flow of

* communication across all the levels of stakeholders in the project. It also gives adetailed record keeping procedure.

It is important for a proper monitoring and evaluation plan to be in place for theproject for its successful implementation. Hence, a Monitoring plan in-order to

* evaluate the progress and for continual improvement is given in this section.

* The budgetary provision for implementing the EMP in the project is made in thissection. It gives activity wise cost break-up.

During the EA study it was observed that there are data gaps and lack of clarity in* developing guidelines in certain sectors. However, it was felt that these information

could be obtained in the course of implementation of the project. Hence,,a list ofspecial studies to be undertaken is listed in this section which would be taken up in

* the first year of implementation.

* PB-PKP/ Ver-3/04-10-05 Page . 1

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* 2. Management Measures

* The proposed project has assigned importance to environment management for

* enhancing the positive impacts and mitigating the negative impacts of the proposedactivities. Therefore, a set of guidelines has been prepared based on the analysis of

* the positive and negative environmental impacts. The environmental managementmeasures to enhance positive impacts for the various activities of the KHNPP

* components are given in the following table. These measures are identified for eachactivity at a broad level. The guidelines for the same are given in Appendix:

Table - 1: Management measure

* No. Activity Management Cross- ResponsibilityMeasure reference

* A ICF - Investments1. Preparing the Incorporating all Appendix A DHO, District-level

* proposal for new planning and design Engineerconstruction of guidelines

*__ PHC/PHU/SC* 2. Review of the Verifying all planning Appendix A ICF Proposal Review

proposals for the and design Committee &

* new construction guidelines Environmentalof the PHC/PHU/ Officer

* SC3. Construction of Ensuring that the Appendix B District-level

* the PHC and SCs design and Engineerconstructionguidelines are

* adopted on site.4. Preparation of Inclusion of Appendix A - District-level

* the Service environmental issues (i) Engineer and DHOImprovement in these district level

* Plans plans5. Performance Performance on Appendix A - State-level ICF

review of the environmental (i) Performance Review* Service management issues Committees

Improvement will be included. This* Plans will be based on the

periodic internal* (quarterly) &

external (annual)* monitoring reports

6. PHC and SC All the operational Appendix C Environmental-in-operation guidelines will be charge at the PHC

* followed and SCs

* PB-PKP/ Ver-3j04-10-05 Page * 2


-No. Activity Management Cross- Responsibility

* _______________ Measure referenceB ICF -

* OrganizationalDevelopment

* Meetings and Environmental issuesdiscussions of / concerns are

* the core group of discussed as an* Commissioner, agenda item in these

Project Director, meetings.* Director (H& FW)

and DHOs* C Studies

1. Use of ODS in Development of a Appendix D i State Environmentalappliances plan to phase-out Officer + External

the use of appliances consultantsusing ODS in the

* PHCs and SCs.2. Training need ass Carryout a detailed Appendix D ii State Environmental

* training need Officer + Externalassessment in all the consultants

* fields related toEnvironment

3. Infrastructure Identification of Appendix D State Environmental

* needs deficiencies and iii Officer + Externalassessment preparation of an consultants

* action plan.D Environmental

* Training1. Integrating Training of state- State Environmental

* environmental level engineering Officers

* issues in design staff and contractors& construction

* 2. Intemal Training of AssistantMonitoring Engineers

* review3. Staff of PHCs and Training of all PHCs

* SCs4. Camp Training of PHC and

management SC staff on how to* manage

environmental issues* in camps

5. Updation of Comprehensive mid- State Environmental

* Environmental term review of the Officer and externalguidelines environmental consultants

guidelines based onthe implementationexperience

* PB-PKP/ Ver-3/04-10-05 Page . 3


* No. Activity Management Cross- ResponsibilityMeasure reference

* E Others1 District Planning Participation of the Project Director and

* Committees SPCB representative State Environmentalin the periodic OfficerCommittee meetings

* 2 Project funding Environmental Project Director andto other existing guidelines of this State Environmental

* schemes / EMP as relevant to Officerprogrammes of these activities will

* the Health be implemented____ Department

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3. Best Practices

3.1 Drug Redistribution Practise* Some of the institutions have the practise of redistributing the medicines which were

nearing the expiry date to other institutions that had a higher probability of utilisingthem before the actual expiry. This practise should be institutionalised.

The procedure adopted is as follows:* . Monthly meetings are convened in the DHOs office, wherein the Pharmacist

has to declare the names, quantity and date of expiry of the drugs and the* quantity that the particular institution can spare.

. In addition, another list is made of the drug requirement for the subsequentmonth along with the quantity requirement.

* . In the meeting, these lists are matched and the exchange is undertaken.. The inventory list is then updated and submitted to the DHOs office.

This is a good practice and can reduce the quantum of management of expired* drugs.

I * 3.2 Landscaping and gardening* Landscaping and gardening was done in one hospital in Dharwad taluk and it was

observed that the general cleanliness of the hospital was good. All the staff* contributed in the effort. An aesthetically pleasing environment discourages dumping

of waste in the premises. This is suggested to be followed in all hospitals. Necessary* budgetary provision would be made for these activities. The procedure adopted for

gardening is as follows:

. The doctors, paramedical staff and the class IV employees together plan thelayout of the garden and saplings to plant.

* . The staffs in their lean period undertake gardening activity.. Fruits and flowers are shared by all the staff

-3.3 Repairs

* At present all major and minor works are carried out by the engineering departmentof the Zilla Panchayat. This procedure caused undue delay in attending to the worksand usually aggravated the situation. Some staff contributed their personal funds toengage a private agency to rectify these works and it was seen that the hospitalsshowed a sense of well being. An impressed amount is maintained by each PHC in-

* charge which is used for minor repairs. Necessary budgetary provision may be madefor use at the discretion of the Medical officer.

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* PB-PKP/ Ver-3/04-10-05 Page.* 5


S 4. Organisational structure

In line with the opinion expressed by experts and discussed with the PHRD groups, ite is proposed to have a new wing called Karnataka Health Systems Development and

Reforms Project, to ensure unified approach and policy which will work through the* existing departmental structure under the Department of Health and Family Welfare,

Government of Karnataka. This department is proposed to execute this project aswell as build sufficient capacity within the department to sustain and expand the

* project-introduced processes to other health programmes in the long run. It willtherefore be possible to implement the project through the existing DHO staff at the

* district and taluk levels. Additional staff as proposed for the KHSDRP will take theadditional responsibilities of EMP implementation.

Figure -1 Organisational structure for EMP

Hefh& Fnamily Welfare* Ir ~~~~~~~~~~~~~~~~~~~~~~~~~Minister l

* _ _ _ _ _j

[S SecretaryHealth & Family Wefare

commissionerHealth & Family Welftare

Oirecbr- Health | Projectepty Pjec* ~ ~~~~~~~~~~~e brlc AdmiinistratorA/KA

rAdministrator ICF ChiefAdminltbafi |HMSE ma| AdmPHCFl * Strategic PlarnIng Cali1 Officer Innov.Schemes

0 MM18 PPM.H nsuranee

/ Jot Direcbr D J c t P eputy Dlrector a Inno.Schemes Deputy Director Deputy Directr

c HQA- HeadQuarterAssiant (r m s r ODm Finiratncing tDPPP PHCF

PC_uiHlco tteu, n c cHallenge Fd | - r_ I OMce~~~~~r In each |I _. _DN09). - I

Development IaS/e Assist ant Adi str rative tevice/istrnatin AinitrtvSvi

* PB-PKP/ Ver-3/04-1-05 Page 6

0 ~~~'|DcorIwag


* The SNOE and DNOE will be stationed at Bangalore in the KHSDRP office (formerly referred toas KHNPP). The Assistant Engineers will be stationed at the Districts who will report to theDistrict Health Officer. At the institutional level, the Doctor-in-charge of the PHC/PHU will be

* responsible for implementation of EMP.

* Table - 2 Roles and responsibilities of various levels of officials involved inKHNPP for EMP

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* SlI.No. Levels/ Department Designation Roles Responsibilities* _____ tiers under EMP

1. State KHNPP State Nodal Officer Overall * Ensure that all* (Environment) coordination Environmental

(SNOE) with a rank of the project guidelines* not less than Joint suggested in

Director this EMP iscomplied withat the variouslevels of

* organisation. Final approval

* of ICF disbursalwith respect to

* EMP criteria. Co-ordination

of state level* planning with

respect to* health &

environment* aspects and

netwroking with* ____ _____ other agencies* 2. State KHNPP Deputy Nodal Liase with all . Arranging

Environmental the DHO and external audits* Officer (DNEO) his staff in and analysing

(Environmental/civil matters of audit reports* Engineer with technical . Developing

minimum 3 years concern and plans and* of experience in advice the procedures for

carrying out audits SNOE environmental* of medical compliance* establishments, . Co-ordinating

should have worked with third party* with leading institutions

consulting houses) . In-charge of* training

activities on*______ __________ environment

3. District District District Health Coordination . Nodal officer of

* PB-PKP/ Ver-3/04-10-05 Page. 7


_ SI.No. Levels/ Department Designation Roles Responsibilities*____ tiers under EMP

Health Office Officer of the district BMWM for all* level. the institutions

Administrative in the district* head . Conduct sample

field visits ofevery districttwice a year forreview of

* compliance onEMP

. District in-charge of

* activities ofKHNPP

* Approval of billsrelated toinfrastructure

* 4. Taluk District Assistant Engineer Supervision . Interacting withHealth Office (Graduate Civil and execution architects and

* Engineer with of contractors tominimum 5 years construction, prepare

* experience in repairs and masterplan asproject maintenance per themanagement) in the district guidelines

* . Preparingbudget

* . Preparingcompliance

* reportCertifying the

* bills* 5. Institution PHC/ PHU Doctor in-charge Environmental * Implementation

In-charge of EMP for* institutional

level* . Implementation

of BMWM

* PB-PKP/ Ver-3/04-10-05 Page . 8

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5. Training & Capacity Building Plan

All the staff of the KHNPP would undergo varied degrees of training on environmentalmanagement under this project. It would commensurate with the responsibilities and

* the staff would accordingly be made accountable for the activities coming under theirpurview.

A refresher programme would be carried out once in six months. The course would* be conducted by professional agencies with real life case studies. Results of the

internal audit would be discussed and the solutions evolved from the group. This~ * inculcates the involvement of the group and fosters their commitment towards the

environment. Depending on the various grades a group of persons would be* identified who will function as trainers for the others. All new inductees into the* department would mandatorily undergo this programme.

* This training plan is laid out with regard to topics that need to be addressed.However, since a need assessment is not carried out, the exact modules and

* subtopics and level of information that needs to be imparted to the trainees is notknown. This will require a Training Needs Assessment Study to be undertaken for

* which a TOR is suggested in Appendix -D.

* 5.1 Target groups for environmental training

State level

Joint Director (Environment)* Staff of the KHNPP

State Institute of H & FW Deputy Director (IEC)Directorate of H & FW - DD (Health, Education & Training)

v Directorate of H & FW - JD (Health, Education & Training)Pub'ic Health Institute Representatives

* Health CommissionerDeputy Director & Joint Director (Malaria Control & Filaria Control)

* AD - Communicable Diseases / AD - Primary Health Care

* District level

District Officer

District Health Officer* District Health Education Officer / Dy HEO

District Nursing Officer

DPIO

DPIO (Deputy Director)Public Health Specialist

* Accounts & Finance SpecialistEngineer (Assistant Engineer)

* Management Specialist

| PB-PKP/ Ver-3/04-10-05 Page *9

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* District Training Centres

Principal* Health Education Officer

District Nursing Officer

ANM Training Centre (19)

Principal1 representative from the faculty

Lady Health Visitor Training Centres (4 - 1 in each Divisions).

Principal1 representative from the faculty

Health & Family Welfare Training Centre (4 - 1 in each Division)

Principal* 1 Communications Officer / 1 Health education officer

* Taluka level

* Taluka Health Officer (THO) / Block Health Extension Educator (BHEE)

* ~~~~PB-PKP/ Ver-3tO4-10-05 Page *10

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5.2 Training calendar for one year

SI.No. Topics 2005

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

6. Awareness 9 6programme on day dayEnvironment and s sBMW - 3 dayprogramme in 15division

7. Refreshertraining for all 2 2staff - 1 day day daysseminar s

8. Internal 3 3reviewers day daystraining - each sdistrict

9. On the job- 3 3review training day daysat Institution s

10. Communication 1 1Skills inci record day daykeeping

11. Waste 1 1 1 1 Xday 1management day day day day daystructureConstruction/

PB-PKP/ Ver-3/04-10-05 Page. 11

SI.No. Topics 2005

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

operation andmanagement

12. Legal Aspects 1day

13. Any other need As and when requiredbased training

14. Preparation forseparateprogramme forother supportingstaff ofdependantagencies -GP/ZP/PWD

PB-PKP/ Ver-3/04-10-05 Page. 12


* 5.3 Formulation of Training PolicyEven though training is primarily the responsibility of the HR /Personnel Department,

* a suitable training policy has to be evolved by the top management. It should reflectthe primary and secondary objectives of the KHNPP with relation to environment. A

* training policy should be able to provide answers to the following questions:

1 What do you want and hope to accomplish through training?* 2 Who is responsible for the training function?

3 Should the training be formal or informal?* 4 What are the training priorities?

5 What types of training is needed?* 6 When and where should training be given?

7 Should training be continuous or casual?* 8 How much should the employees be paid during training?

9 Which outside agencies should be associated with training?* 10 How should training be related to labour policy?

5.4 Draft Training Policy

* All expenditure including travelling and daily allowance claimed during training* shall be considered under the head of training;

* All employees shall be categorized as below for purpose of training;o Top Managers: All DHOs/equivalent and aboveo Middle Managers: THOs/equivalent and above, ando Others : All others;

* . All staff will undergo in house training about their duties as soon as the newpolicy is enforced;

* . All employees shall undergo minimum of 7 days training every year;* Attending conference, exhibition, Brain storming session will not be treated as

* training and workshops will be treated as training;

* PB-PKP/ Ver-3/04-10-05 Page. 13

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* 6. Communication Plan

6.1 Environmental declaration* There would be an environmental policy for the project. All policy level statement on

the environment should be accessible to the entire staff and the public. Posters,* boards with the policy written on it and signed by the Heads, Medical officer and all

the staff should be displayed at each of the PHC and PHUs

6.2 Distribution listA distribution list of all documents should be maintained. In case of any revision, the

* revised documents should be made available to all as per the distribution list. Theflow of distribution for each of the document in the hierarchy should be as per the

* organisation chart given in Chapter 14. However, this will vary depending on the typeof communication and the target.

6.3 Regular meetings with support institutionsSince the PHCs and PHUs are dependant on other institution such as ZP, Panchayath

* for their working, it is recommended that a periodical joint meeting be held reviewthe environment aspects and proper functioning. The meeting could also be attended

* by prominent citizens, NGOs in order to be more effective.

* 6.4 Environmental Management Information BoardAll the waste disposal measures implemented in the PHUs/PHCs should be

0 highlighted prominently using didactical boards at vantageous locations. The general* public and staff should have access to them.

* 6.5 Complaint Phone Number with centre in DHOA dedicated telephone number, address, and email of the concerned Environment in-

* charge should be displayed at the reception. The public should be encouraged toreport any deviation occurring in the PHC/PHU. A system of reward for provencomplaint should be implemented. Suitable budgetary provision should be made.

6.6 Rewards & Recognition mechanism for environmental* compliance

Complimentary to the previous suggestion, a scheme of rating the individual PHCs* and PHUs at district level for environmental compliance should be developed. This

could be a direct result of the internal audit mechanism. The successful PHC maythen compete with inter district for a state level award. A scheme of certifying at the

* PHC level with token monetary benefits for the staff will help in motivating them.

* 6.7 Joint environmental programmes with KSPCBKHSDP should avail the services of the KSPCB and carry out training programmes for

* stakeholders- Own staff, ZP, public, NGOs on the beneficial aspects of a goodenvironment. Services of NGOs who are already working in the field of health,Literacy and sanitation should be solicited. A state level and district level committee

* should have KSPCB representative at each level. At the district level the regionalofficer as a member of the district level committee. At the state level, a Senior

* Environment Officer (SEO), in-charge of BMW to be a member.

* PB-PKP/ Ver-3/04-10-05 Page * 14

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* Final Report Karnataka Health, Nutrition & Population Project (KHNPP)

* 6.8 RecordsThe PHC/PHU should be insisted on maintaining daily log of waste generated (This is

* as per the BMWM Rules, 2000 and is mandatory). Proper co relation with actualconsumables used should be made and reasons for variation analysed. This should besent to the district health office, where comparisons can be made with other PHCs

* and PHUs. Preferably a soft copy of the data should be sent in MS Excel form whichwill help in analysing.

A model specimen of the daily log is given under

Name of the institution: PHU/PHC Month* Address:

Table - 3 Model log for inventorisation of BMW

Date No of No of Type of Quantity Mode of Opening Accumulatedinpatients outpatients waste in kgs disposal balance quantity

* 18.08.04 10 63 Glass 0.250 Disinfected 2.310 2.560items and stored

* Syringes 0.055 Disinfected 1.230 1.285with and stored

* needlesSwabs, 0.080 Deep 1.650 1.730

* cotton burial pitsandother

* ~~~~~~~~~~~infectedmaterial

* Other 0.30 Municipal 5.80 6.100non solid

* Binfectious wastewaste

* 19.08.04 9 54 Glass 0.1 Disinfected 2.560 2.910items and stored

* Authorised Environmental officerDate

* A signed copy of this statement has to be sent to the DHOs office on or before 7th offollowing month. Once the weight of the stored materials reach a threshold value it

* should be sent safely to the DHOs office or other designated places where it properdisposal action for recycling can be taken.

0P V

PB-PKP/ Ver-3/04-10-05 Page.+ 15


7. Proposed Consultative Process & Disclosure Plan

* The public consultation process that needs to be undertaken during theimplementation stage of the project is given in this chapter. This is as per the

* suggestions of the public consultations undertaken as part of the EA.

* 7.1 Stages of Consultative Process

* The different stages of consultative processes to be involved in the project right from* the start in different phases are as follows:

* Table - 4 Stages of consultations in EMP suggested for the project

* Stages Responsible Specific activities/Outputs expectedparties

* Project DoHFW o Information about the project will be madeAnnouncement known to Panchayaths, DHOs office, Department

* of Forest, Environment and Ecology andKarnataka State Pollution Control Board offices

* o World Bank PADo Project information dissemination through mass

* _______ mediaInitial Project DHO's office o Briefing of the project (its scope, objectives and

* Introduction through IEC possible benefits) to the District Health Personnelrepresentative (Doctors, Nursing staff and all paramedical staff)

* Project Doctor In-charge o Briefing of the project (its scope, objectives andIntroduction at of the PHC possible benefits) to GP members in the villagePanchayath (s) in the villages where new PHCs and SCs arelevel to be located. This is undertaken to consult the

villagers for the following:* Locating the PHC* Environmental precautions to be taken

Formation of Nursing in-charge o This group will act as a watchdog group in orderVillage level with the help of to check the guidelines prescribed for BMWM andHealth & KSPCB regional EMP (group members to be trained prior)Environment office official o Tree planting activities to be undertaken in theGroup hospital premises on Environment day and Earth

day

7.2 Specific mechanism for community involvement

(a) Proposals put forward to the ICF should be discussed in the gram sabha* and should have the approval / consent of the gram sabha

(b)In preparing the Service Improvement Plans at the District level, theDHOs will necessarily consult the community.

* (c) As the PH Fund is meant to encourage any organization (includingcommunity organizations) towards better public health, there will be

* community involvement for deciding the PH fund disbursal.(d)Proposal should be certified for compliance to the EMP guidelines by the

* District Environmental Nodal Officer and the State Environmental NodalOfficer.

PB-PKP/ Ver-3/04-10-05 Page + 16


7.3 Public Disclosure of EMP

* The Executive Summary, EA and EMP is planned to be disclosed in the District HealthOffices and in the KHSDP office in Bangalore. The Kannada version of the Executive

* Summary will also be disclosed at these offices.

* A copy of the Kannada version of the executive summary of this document will alsobe made available at the District Health Offices.

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* Final Report Karnataka Health, Nutrition & Populatlon Project (KHNPP)

8. Monitoring Plan

* It is suggested that at least one officer (DHEO,DNO,DPIO of each district undergo atraining programme related to environment conducted by EMPRI/ KSPCB etc. These

* officers should carry out internal review of the PHUs and PHC under the district andsubmit a report to the DHO. The concerned Medical officer/THO/DHEO/DNO

* Environmental incharge should be responsible to correct the non conformance and* prepare a preventive action plan for the PHC/PHU. A followup review of the institution

should be carried out after one month. This should be carried out at least once in* three months initially and may be once in six month later on.

* 8.1 Internal auditAn internal audit of any district by an auditor/s from different districts should be

* mandatorily carried out once in six months.

* The results of the internal review findings should be circulated and discussed at a* state level meeting of all Environmental officers. Appropriate corrective and

preventive action should be then institutionalised if needed. The state level meeting* should be held at least once in six months.

* 8.2 External auditThe KHSDP should retain the services of external consultants for an independent

* audit a sample of the PHC and PHUs. The audit team should include at least one* internal auditor from KHSDP to ensure follow up actions. The relevant actions

necessitated as a result of the review should be completed within one month of the* review.

* Table - 5: Monitoring measure

* lMo. Activity Monitoring Cross- ResponsibilityMeasure reference

1. Internal environmental Minimum 10% TOR for Concerned District* review of PHC/PHUs in random sample of environmental Environmental

d istrict each district reviews Officer* 2. External Minimum 2 % TOR for Independent agency

environmental random sample of environmental or other District* surveillance review of each district reviews Environmental

*__ PHC/PHUs in district Officer

* 8.3 Gram SabhaA village level watch dog group should be formed under the Gram Sabha to monitor

* the project, especially the BMWM practiced at the PHC level. The group should begiven basic awareness programme on what are the do's and don'ts regarding the

* treatment and disposal of BMWM. They should be encouraged to monitor andevaluate the disposal structures and use the complaint facility. Regular stock taking

* of this group in the village panchayat meetings should be encouraged. Their* participation should be solicited during important events like Environment Day, Earth

Day, Independence Day etc., by encouraging tree planting in the PHC premises.

PB-PKP/ Ver-3/04-10-05 Page . 18

-


* 9. Budgetary Provisions

* The projected cost for implementing the EMP and unit cost for certain infrastructurewhich requires funding from ICF is given in tables below. These costs are to be used

* for making provisions for the Environmental aspects to be included in the overallbudgeting for the project. The basis for calculation of each element is obtained from

* the discussion with the concerned Engineering division and the administrative* department of the KHSDP. The budgeted costs for the civil works under the ICF are

only indicative and are depended on actual site conditions.

-Table - 6 Budget for EMP

No. Description Amount Assumptions / Basis(Rs. (USD

* million) million)

* 1 Organizational Costs

Salary of Joint Director 5 years x 12 months x* (a) (Environment) 1.80 0.036 Rs. 30,000

* Sub-total: 1.80 0.036

2 Training

* State level trainingEnvironmental awareness 2 programmes / project

* (a) training atthe state level 0.05 0.001 period xx 1-day programme x

* Rs. 25,000 per 1-dayprogramme

* District level trainingEnvironmental awareness 0.0476 5 programmes / project

* (b) at the 2.38 period x1 programme / eachequivalent District x 19

* Districts equivalent Districts1-day programme x Rs.

* 25,000 per 1-dayprogramme

Training of District-levelEngineers and Public 0.0476 5 programmes / project

* g (c) Health 2.38 period x1 programme / each

i * Specialist to do periodic equivalent District x 19internal monitoring review equivalent Districts

PB-PKP/ Ver-3/04-10-05 Page * 19



* million) million)2-day programme x Rs.

* 25,000 per 2-dayprogramme

0 Taluk level trainingTaluka level training for

* Environmental skills 0.49 all PHCs and PHUs -(d) training in the PHCs /SCs 24.50 175 talukas

Two 1-day training forselected for monies from each taluka - Rs. 10,the ICF 000 per 1-day

* programmeTA+DA = Rs. 100 percandidate

Development and* Curriculum development 0.04 delivery of train-the-

(e) for training institutes at 2.00 trainer manual + 1* various levels - train-the-

trainer manuals Revision.* Sub-total: 31.30 0.626

* 3 Communication.

Hospital Waste & 2 copies for 1676 PHCs* Environmental + 383 PHUs + 175 THO

(a) Management Plan 0.5 0.01 + 27 DHOs+ 19 DTCs + 4 HFWTCs+ 4 LHVTCs + 1 SIHFW

* A Manual +

* 19 ANM TCs10 copies for HETs

* 10 copies forDirectorate100 copies for the staff

* About Rs. 2.6 lakhs forpreparation

0 (b) Posters 3.30 0.066 PRs. 100 / posters x 3(b) Posters 3 30 0.066 posters x (2000+9000)

(c) Models for display at DTCs 0.30 Rs. 15,000 x 19 DTCs +

PB-PKP/ Ver-3/04-10-05 Page * 20



* million) million)0.006 1 State Project Office

* Sub-total: 4.10 0.082

4 Monitoring

External environmental 1 external monitoring

* (a) monitoring review 1.25 0.025 every year x 5 years;

* Rs. 2.5 lakhs per review

Sub-total: 1.25 0.025

* 5 Special studies

Study on pesticides used in* (a) primary health care 0.40 0.008 Estimate - Rs. 4 lakhs

Training needs assessment(b) on health care waste/ 0.30 0.006 Estimate - Rs. 3 lakhs

environmental issues

* Adequacy and needsassessment of 0.024

* ©3 infrastructure for 1.20 Estimate - Rs. 12 lakhsenvironmentalmanagement

Glass Vs AD / Disposable* | (d) Syringes - A comparative 0.50 0.01 Estimate - Rs. 5 lakhs

study

| * Sub-total: 2.40 0.048

* Grand total (Rs.* Million): 40.85 0.817

Table - 7 Budget for Civil Works

No. Description Unit Cost s Assumptions / Basis(Rs.) (USD.)

| * 1 Civil Works

(a) PHCs

PB-PKP/ Ver-3/04-10-05 Page * 21


No. Description Unit Cost s Assumptions / Basis(Rs.) (USD.)

Biomedical wastes* Deep burial pits under Needles, glass vials,

roofing + Sharp 1500/- slides, brokenmanagement pits under glassware and broken

* roofing Rs. 75, 000/- syringes

* Shelter for lime and mud Rs. 10, 000/- 200/-

Shallow pits without All general wastes -

* roofing Rs.500 10/- organic (paper, food)

* Dedicated enclosure oftender coconut shells Rs. 800 16/- Coconut shells

* Primary, secondary,2000/- tertiary plant + Soak

* Sewage treatment plant Rs. 0.1 mill. pits

* (b) SCs

* Shallow pits without* roofing Rs.500 10/-

* Dust bins Rs. 800 16/-

(c) Landscaping

Green cover - per 0.4/-* sapling Rs.20

* (d) Compound wall

Low-cost stone / granite* slabs (4-acre plots) Rs. 0.5 million 10,000/-

All the above costs have been discussed with the Engineering Division whichimplements the project. This has been incorporated in the PIP costs by the

* Finance team for the overall budget.

- PB-PKP/ Ver-3/04-1O-O5 Page * 22

0 ~~~Final Report Karnataka Health, Nutrition & Population Project (KHNPP)

SSS

* APPEN DICESSS

SSSS

S

S

0SS

0 ~~~PB-PKP/ Ver-3/04-10-05 Page * 23

S


A. Planning and design stage guidelines

The planning and design guidelines are to be followed by the respective departmentsinvolved in planning of a new PHC/PHU/SC building or planning construction of new

* infrastructures for the Health Care Institutions.

i. Environmental Checklist for the ICF Proposal Review Committee* Almost all environmental aspects causing negative impacts can be managed by* proper mitigative measures and a committed environmental management. Hence as

long as the Environmental assessment and Environmental management guidelines* given in this report is incorporated, all proposals have an equal chance as far as

environmental compliance is concerned

However, in a prospective case of selecting a particular location or design of a PHC* for funding, it would be appropriate to evaluate it on its merit of the costs of0 Environmental compliance and approve the proposal on economic considerations.

0 The following method is suggested to evaluate the proposal at the approval stage* itself. The proposal review committee should recommend the funding based on this

method.-

The environmental parameters of the proposal have to be evaluated using the table* given below. The compliance of the proposal for each of the attributes has to be

ranked on a scale of 0 to 5. Zero being non compliance and 5 being highest degree of* compliance. Each attribute has been accorded a weight in relation to the degree of* impact on the environment. The score for each attribute is obtained by multiplying

the rank with its corresponding weight. Finally, the individual scores are summed tov obtain the total score for the proposal.

* The proposal with the lowest score implies a higher financial outlay for managing theenvironmental aspects and should be given a low priority.

Table - 8 Evaluation Matrix for funding proposal under ICF

* ~~~~~~~~~~~Rank ona scale of Weighted

* SI.No. Environmental Attributes Weights 0 to 5 scoreW R S=W*R

* A Land

* 1 Extent of land 4

2 Clear land titles 6

B Siting guidelines1 Location 10

* 2 Water supply sources 5

* 3 Ground water table level 5

PB-PKP/ Ver-3/04-10-05 Page * 24


Rank ona scale of Weighted

* SI.No. Environmental Attributes Weights 0 to 5 scoreW R S=W*R

* Accessibility and Width of4 approach roads 5

* C Building planning criteria

* 1 Setback 1.80

2 Surface grading 1.80

* 3 Plinth height 1.40

* 4 Ceiling height 1.40

5 Floor area 1.40

6 Plastering and painting 1.40

* 7 Access to terrace 1.40

* 8 Water proofing course (WPC) 1.80Concrete paving around

* 9 building: 1.40Compound wall and entrance

* 10 gates 1.80

* 11 Distance from electric lines 1.40

12 Water 2.25* Sanitary and other

13 infrastructure 2.25

14 Electrical infrastructure 2.25

* 15 Lighting 2.25

* 16 Ventilation 2.25

17 Parking area 2.25

18 Landscaping 2.25

* 19 Noise reduction 2.25D Construction guidelines

1 Debris management 6.00

* 2 Felling of trees 4.00

E Operational guidelinesWater supply infrastructure

. * 1 maintenance 1.4Sewerage infrastructure

* 2 maintenance 4.6Vehicular infrastructure

* 3 maintenance 1.4

* 4 Biomedical waste management 4.2

5 Review External and internal 4.2* Environment monitoring* 6 activities 4.2

PB-PKP/ Ver-3/04-10-05 Page + 25


* Overall Rankini l

Poor 0-100

Fair 101-200

* Satisfactory 201-299

* Good 300-400

Excellent 401-500

* ii. Guidelines for incorporation environmental aspects into ServiceImprovement Plan (SIP)

0Care should be taken to ensure that in the process planned in the SIP, Environmental

* degradation are not inadvertently caused. Hence the following checklist should beused

1. Whether proposed SIP is likely to cause any pollution ona. Soil

* b. Waterc. Air

* 2. Extent/volume of service is estimated correctly3. Projected volume (Population increase, Increased coverage, Reduced/ health

* problems, additional service )until the next improvement phase has beenaccounted for in the design of the components affecting and or managingenvironment

* 4. The implemented/ available environmental management measures areadequate to cater to the projected population

* 5. Budgetary provision has been made to account for the implement, operate andmaintain the management measures

* 6. Organisational infrastructure has been made available for maintaining the* Environmental management system.

7. Systems are in place for the review, analyze, modify and implementappropriate changes in case of inadequacy.

I * iii. Environmental Guidelines for siting of a PHC/PHU/SCThe selection of site should be undertaken by first preparing a list of potential sites

* on the basis of availability of required extent of land and Compliance to the locationalcriteria.

-a. Availability of required extent of land:

* The area required for the institution depends on the facilities extended by it and tothe population served. Minimum areas for each essential component of the building isgiven later on in this section. Apart from this, the mandatory area required for

* landscaping also has to be accounted. Presently, the Health department specifies aminimum requirement of 4 Acres, taking into consideration future needs for

* upgradation of facilities.

* b. Compliance to the locational criteria:

_ PB-PKP/ Ver-3/04-10-05 Page * 26

0Final Report Karnataka Health, Nutrition & Population Project (KHNPP)

While the PHUs and PHC building infrastructure could be located in a region from the* considerations of demand and accessibility, the waste management structures like

Septic tanks, deep burial pits and safe needle pits etc require to be sited properly.* BMW management structures should not be located within a certain distance of the

following: Water bodies, Flood plains, Wetlands, Civil structures, Water supplysources. The following criteria may be looked into while selecting the location. Since

* most of these structures are located within the hospital premises, these criteria alsogovern the location of the PHUs indirectly.

The land chosen has to comply with certain minimum criteria in order to reduce* negative environment impact. To aid in the selection, collection of preliminary site

relevant data is vital. They are as follows:

c. Preliminary site data:

* Topography:The project site should not be located in areas which are not on natural surface water

* drains or flood plains. The topography should be gentle terrain with the ground beingflat or with a cross slope not exceeding 3%. It should preferably be on a higher level

* than the neighbouring sites. The Survey of India's topographical maps on 1:25000scales will help in identifying these sites. It also helps in locating the existing water

* bodies and rivers.

* Geology:* The type of BMWM structures to prevent contamination of soil and water, type of

foundation for the PHC structures, depth of foundation are determined by the* geology of the area, which in turn influence the cost of the projects. The Geological

maps available from Geological Survey of India, help in indicate the bedrock level* and the type of soil available. A fair assessment of permeability can be made based

on this. Inspection of open excavation and interviews with local people will aid in* corroborating the data. Shortlisting sites with a favourable geology helps in. g optimising costs.

Groundwater:* Ground water contour maps are available from Dept. of Mines and Geology and

Ground Water Boards. The information on depth of ground water table level,* seasonal fluctuation and direction of flow can be obtained. Interviews with people in

the vicinity will also help in establishing the same. Water quality data should also be* obtained. These will help in setting up monitoring wells for measuring any

environmental degradation due to the PHC.

* Rainfall data:These data can be obtained from the Indian Meteorological Dept. The data is useful

* for designing the surface runoff interception drains for storm runoff management.

* Wind data:These data can be obtained from the Indian Meteorological Dept. The predominant

* wind direction can be used to locate the BMW management structures and the vent* pipes to avoid the nuisance of foul odour within the premises.

. PB-PKP/ Ver-3/04-10-05 Page * 27

.

* ~~~Final Report Karnataka Health, Nutrition & Population Project (KHNPP)

iv. Land-related Guidelines for siting of a PHC/PHU/SC

After the location of the PHC/PHU/SC is established, it is required to determine the* ~~land related siting criteria which is as follows:

Water bodies and rivers: No BMW management structures shall normally be* ~~constructed within lOOm of a surface water body. This is due to the concern that the

surface runoff of waste contaminated water during storms into the water body.

Flood plains: In case the structures has to developed within a flood plain of a* ~~secondary stream, an embankment of adequate height has to built around it to avoid

flooding of the area.

Wet lands: No structures should come in designated wetlands. Contact KSPCB foradvice on the same.

Civil structures: A setback of at least 6.Om should be ensured between soak pits* ~~connected to septic tanks to avoid distress to the foundation of the buildings.

* ~~Water suDDlvl sources: No BMW structure shall be located within 18m of a drinkingwater sources such as an open well, deep bore well. This distance should be more incase of fissure rocky strata or limestone strata etc.

Gro und water table level: No structure shall be located in areas where the ground* ~~water table is less than 1.0 below the base of the structure at any point of time.

* ~~~~~~~~~~Figure - 2 Siting and Locational criteria

4 ~~~~~~~~~BM 1 NM structure,

6 rr PHC/,PHU

0~~~~~~~~~~~~o

* ~~PB-PKP/ Ver-3/04-10-05 Page .28


* The distance marked in the drawing are minimum and is intended to be a guide for

locating the various components.

* Accessibility: The PHUs and PHCs should be located close to a bus stop. It should not

be too close to a NH or State highway in view of noise pollution. Nor should it be near

* a municipal land dump site to reduce odour and noise problems.

* Width of approach roadsThe width of roads is dependant on the length of the approach road to the PHC/PHU.

* The length of the road shall be determined by the distance from the farthest plot(building) to the public street. It shall not be less than the following.

* Width of road (m) Length of approach road (m)12 200

* 15 40018 600

* 24 Above 600

l ~~~~~PB-PKP/ Ver-3/04-10-05 Page 29

| * Final Report Karnataka Health, Nutrition & Population Project (KHNPP)

v. Planning and Design criteria for building and infrastructure* guidelines

On the completion of the locational criteria and land related siting criteria fulfilment,* the planning and design criteria for building and other infrastructure should be

undertaken.

. * Setback: The hospital should have a setback of atleast 12m in the front and the otheropen space shall be not less than 6.0m. However this distance shall be atleast 18 m

* from the BMW management structure and WWTP. This will minimise the risk ofcontamination of drinking water source located by the neighbours.

* Surface grading: The surface has to be regarded to ensure that storm does not runoffinto the campus. Interception trenches/ drains of adequate size should be

* constructed depending on the rainfall and topography of the site.

* Plinth height: The plinth should be so constructed that adequate drainage of the siteis ensured. It should in any case be less than 450mm above the finished ground level

* of the vicinity.

Ceiling height: The height of the building should not be less than 3.Om

Floor area: The PHCs/PHUs should comply with the minimum area required as per* relevant IS. However, an additional waiting area of at least 30 Sq.m. should be

provided with seating facilities.

Plastering and painting: All the building should be provided with plastering ofspecified thickness. The exterior should be painted with weatherproof paints. The

* inner walls should be painted with washable oil bound distemper and at least thebottom 1.2 m from the floor with plastic emulsion paints. Buildings have to be given

* a fresh coat of paint at least once in two years.

* Access to terrace: All buildings provided with RCC flat roof terrace should havestaircase/ ladder access. This will allow easy access for cleaning of clogged rain water

* down comers and also maintenance of roof mounted water tanks.

* Water proofina course (WPC): Proper water proofing should be ensured. A seven coattar-felt system, or additional WPC with integral water proofing agents or any otherpatented systems may be adopted. The number nf down comers should be

, * appropriate and the WPC should drain into them. Access ladders/ staircase should beprovided to the terrace to maintain the rainwater down comers.

Concrete paving around building: The normal concrete plinth protection provided* around the building should be extended as a paved walkway of at least 2.Om width

all around the building. This will prevent the growth of weeds near the walls whichotherwise leads to accumulation of garbage.

Compound wall and entrance gates: The maximum height of boundary wall shall be* 1.5m above the centre line of the front street. Compound wall of 2.4m may be

PB-PKP/ Ver-3/04-10-05 Page * 30


permitted if the top 0.9m is of open construction or if specifically approved by the* authorities. A concrete block/ stone masonary compound wall of at least 0.9m high

and five rows of barbed wires above it should be built around each PHC/U may be* used from economic consideration. Hedges should be encouraged along walkways

and along compound to increase aesthetics and greenery. The wall will aid in curbing* encroachment and also discourage people from using the open place for defecation.

The entrance to the gates should be provided with cattle traps to prevent strayanimals from entering.

Distance from electric lines: No verandah, balcony or structural projection can extend* to a distance as indicated below to reduce the danger of electric hazards

* Table - 9Provision of set backs from electric lines

* Vertically (m) Horizontally (m)* Low and medium 2.5 1.2

voltage line less than

High voltage upto and 3.7 1.2* including 11KV

High voltage above 11 3.7 2.0* KV and upto 33 KV* Extra high voltage 3.7 2.0 (plus 0.3m for every

beyond 33 KV (plus 0.3m for every additional 33 KV and pat* additional 33 KV and pat thereof)

thereof)

* ~~~~vi.

.Ve

.

.

* PB-PKP/ Ver-3/04-10-05 Page.+ 31


Water supply system planning guidelines

* Ouuntity and quality: Potable quality water has to he provided in a PHC. It isestimated a that a minimum of 3000 litres per day would be required at each PHU/C

* for drinking water and meeting the hospital needs. This is based on a per capitademand of 50 liters and an average 50 number of users.

-Sources of drinking water: Open wells, if provided for human use or domestic

* consumption shall comply with the following locational criteria.

* Open well shall be located at a distance of at least 15m from any ash pit,* refuse pit, earth closet and shall be located on a site higher than the earth

closet.* . Similarly it shall be located at least 18m from any cess pit, soakway or

borehole latrine that contamination by movement of sub soil or soil water is* unlikely,

. It shall not be located under a tree if no canopy is provided.

The well should meet the following requirements:. Have a minimum internal diameter of not less than 1.0m

* . Be constructed to a height not less than lm above the surrounding groundlevel

* . Provided with a paving of impervious material around the kerb extending 1.8maway from the kerb. The paving should be sloped away from the well.

* . The inner surface should be rendered impervious upto a depth not less than1.8m measured from the level of the ground.

In case a deep borewell is provided then it shall be located at least 18 m away fromthe compound wall and the nearest Waste disposal structure.

* Storage requirements: It is estimated a that a minimum of 3000 litres capacity* overhead tank needs to provided at each PHU/C.A sump along with a pump may be

provided in case a municipal water supply connection is provided. The minimum* capacity of the sump should be 9000 litres thus ensuring at least three day backup in

case of contingency and non supply of municipal water. The 9000 litre capacity also* ensures that water can also be procured and transported in large tanker and stored

in emergencies.

v Conveyance requirements: Water may be conveyed through PVC pipes which willreduce problems of scaling and corrosion. All tanks and sumps should be provided

* with float valves. Tanks should be provided with lockable manhole covers for easyinspection and cleaning. The taps should be of push to on type to conserve water.

P

PB-PKP/ Ver-3/04-10-05 Page . 32

.


vii. Sewerage system planning guidelines* Toilets and urinals should be provided as per Water supply and sanitation

requirements of BIS (IS 1172-1983) which is as follows.

* The requirements for fitments are given below.

* Indoor patient wards (for males and femalesWater-closets 1 for every 8 beds or part

* thereofAblution taps 1 in each water closet plus one

water tap with draining* arrangement in the vicinity of

the water closet and urinal for* _______________________ every 50 beds or part thereof

Wash basin 2 up to 30 beds; add 1 or every* additional 30 beds or part

thereof* Baths 1 bath with shower for every 8

*______________________ beds or part thereofBed pan washing sinks 1 for each wards

* Cleaners sink 1 for each wardKitchen sink and dish 1 for each ward

* washer (where kitchen isprovided)Out Datient wards

For males For femalesWater closets 1 for every 2 for every 100

* 100 persons persons or partor part thereof

* thereofAblution taps 1 in each 1 in each water

* water closet closetUrinals 1 for every

50 persons or* part thereof

Wash basins 1 for every 1 for every 100* 100 persons persons or part

or part thereof* _ _ _ _ _ _ _ _ _ _ _ _ _ thereof

* Bathrooms and water closets:The size of the bathroom shall not be less than 1.5m x 1.2 m or 1.8 Sq.m. The floor

* area of water closet shall be 1.1 Sq.m with a minimum width not less than 0.9 Sq.m.If bath and water closet are combined its floor area shall not be less than 2.8 Sq.m

* with a minimum width of 1.2 m.

* Every bathroom and water closet shall be so situated that at least one of its wall shall* open into external air. It shall have a window or ventilator opening to a shaft or open

PB-PKP/ Ver-3/04-10-05 Page . 33


space of area not less than 0.3 Sq.m with side not less than 0.3m. Electrical light* should be provided in the toilet.

It shall not be directly over or under any room other than another water closet,* washing place, bath or terrace unless it has a water-tight floor. It should be provided

with an impervious floor covering, sloping towards the drain with a suitable grade* and not towards verandah or any other rooms. It should be enclosed by walls or

partition and the surface of every such wall or partition shall be finished with a* smooth impervious material or ceramic tile dado to a height of not less than lm

above the floor of such a room.

* Water should be provided through tap and bucket arrangement.

* Sewer systems:It is suggested that 100mm diameter PVC pipes of minimum rating 6kg/sq cm should

* be used for the sewer pipes. A minimum of slope of 1:100 should be ensured. Theconventional clay soil pipes have a tendency to break and leak at the joints. This is

* more prone in the case of loose soil and black cotton soil where there is differentialmovement. PVC on the other hand can accommodate such settlements, besides

* being more water tight and efficient in conveying wastewater. Inspection chambers* or registers of atleast 600x 600 m should be provided at distance not exceeding Oim

and at bends. The chambers shall be covered with cast iron covers.

Wastewater treatment plants:* The Black water from toilets, Minor OT and Grey water from bathrooms have to be

treated prior to discharge in to ground or natural drains. The conventional systems* are a combination of Septic tanks and soak pits which achieve partial treatment. A

more efficient system would be the use of Decentralised wastewater treatmentsystem which are highly efficient. The details are as follows.

* Segtic tanks:* Location: Should not be closer than 18m from the nearest water source. It should no

be closer than 6.Om from any building to avoid structural distress to the buildings.-

Requirements: The Septic tanks along with a soak pits should be designed for a* Wastewater flow of at least 3 cum/day. A 3.Ocum/day shall have the following

dimensions. It shall have a minimum width of 2.0m, a depth of 1.8m below the water* level and a minimum water capacity of 22cum. The length of the first chamber is

4.Om and the second chamber is 2.0m. The design desludging period is once in twoyear. It may be constructed of brickwork, stone masonry, concrete or any suitable

* materials as approved by the authority. Under no circumstances shall effluent from aseptic tank be allowed into an open channel drain or body of water without adequate

l * treatment. The minimum nominal diameter of the pipe shall be 100mm. Further atjunction of pipes in manholes, direction of flow from a branch connection shall not

l * make an angle exceeding 45 deg with the direction of flow in the main pipe. Everyseptic tank shall be provided with a ventilating pipe of at least 50mm diameter. Thetop of the pipe shall be fitted with a mosquito proof cage mesh. The pipe shall extend

* to about 2.Om when the septic tank is atleast 15m away from the nearest buildingand to a height of at least 2.Om above the top of building when it is located closer

* than 15m.

PB-PKP/ Ver-3/04-10-05 Page + 34

I-


* * When the disposal of septic tank effluent is to a seepage pit, the seepage pit shall beof any shape of minimum dimension of 0.9m and not less than 1.0m depth below the

* invert level of the inlet pipe. The pipe may be lined with stone, brick or concreteblocks with dry open joints which should be backed with 75mm of clean coarseaggregates. The lining above the invert level should be finished with mortar. In case

* of pits with large dimensions, the top portion may be narrowed to reduce the size ofthe RCC cover slabs. Where no lining is used especially near trees, the pit may be

* tilled loose stones. A masonry ring may be constructed at the top of the pit toprevent damage by flooding of the pit by the surface runoff. The inlet pipe may be

* taken down to a depth of 0.9m as an anti mosquito measure; and

* When the disposal is to dispersion trench, the trench shall be 0.5 to 1.Om deep and0.3 to 1.Om wide excavated to a gradient and shall be provided with 150-250mm ofwashed gravel or crushed stones. Open jointed pipes placed inside the trenches shall

* be made of unglazed earthern ware, CI or concrete and shall have a minimuminternal diameter of 75 of 100mm. Each dispersion trench shall not be longer than

* 30m and trenches shall not be placed closer than 1.8m.

* Alternatively a better method for new institutions would be to provide Decentralizedwastewater treatments systems (DEWATS) where the treatment efficiency is very

* high and water is available for secondary uses like gardening, landscaping and toiletflushing. This is most appropriate technology in areas of Black cotton soils (nearly27% of Karnataka's geographical area like Dharwad) and areas with low permeability

* where the soak pits cannot work.

Figure - 3 Decentralised Waste Water Treatment System for PHC/PHU

* t nf e ti ti i* A s ,,'

Wstrb~~~ a .. .

Physical settling, chemical adsorption, biological decomposition. It does not require* electricity or chemical and is devoid of mechanical parts for operation. Hence the* system is reliable and cost effective.

0

0

. PB-PKP/ Ver-3/04-10-05 ae3

St


viii. Electrical infrastructure planning guidelines

It is recommended that exposed electrical wiring be carried out in GI conduit only toavoid problems of corrosion. All wirings should be terminated properly. No naked

* joints should be allowed. Earth leakage Circuit breakers (ELCB) or miniature circuitbreakers (MCBs) of adequate rating should be provided for ensuring safety and

* reliability

* Lighting: The recommended lighting levels in various areas of the PHC is tabulatedbelow. These can be achieved by either artificial lighting or natural daylighting byproviding Fenestration (openings) of adequate dimension at appropriate locations.

The lighting requirements in hospitals are tabulated below

*Receptions and waiting 150 Lux

* ~~~~~~roomsWards General 100 Lux

* Wards beds 150 Lux* Operating theatres- 300 Lux

General* Operating theatres- Special lighting

Tables* Laboratory 300 Lux

-Radiology dept 100 LuxCasualty and outpatient 150 Lux

* de t _ _ _ _ _ _ _ _ _ __dpt

Stairs and corridors 100 Lux* Dispensaries 300 Lux

0

0 ~ BPP e-/4-00 ae+30


ix. Ventilation requirement guidelines

An air change of 3-6 per hour is recommended based on maintenance of requiredoxygen, carbon dioxide and other air quality levels and for the control of body odourswhen no products of combustion or other contaminants are present in the air. Theventilation may be effected by the openings, passive air extractors or use of exhaust

* fans.

* Rooms shall have for the admission of light and air, one or more openings such aswindows and ventilators opening directly to the external air or open verandah with a

* maximum width of 2.4m.

I * A general guideline would be that the minimum aggregate area of such openings,* excluding doors inclusive of frames shall not be less than

; One tenth of the floor area for dry hot climate;* . One sixth of the floor area for wet hot climate

- One eighth of the floor area for intermediate climate* . One twelfth of the floor area for cold climate.

For this purpose only the openable portion of the window may be accounted.

x. Vehicular parking infrastructure guidelines

* Vehicular parking area may be provided in the front such that the clear vehicularaccess-way is not reduced to less than 6m. 50% of the open space around the

* building may be used for parking, provided that a minimum distance of 3.6m is keptfree without any parking, loading or unloading spaces. Each parking space for cars

* shall not be less than 13.5sqm and for scooters and cycles not less than 1.25sqmand 1.0sqm. Parking area should be provided as given below

Occupancy One car parking s ace for everyPopulation Population Population less

* 200000-1000000 50000-200000 than 50000Hospitals 15 beds 25 beds 30 beds

In addition to the above parking areas, 25-50% additional parking shall be provided* for parking other types of vehicles and additional vehicles required such as

ambulances.

xi. Landscaping guidelines

.* 50% of the permissible open space should be used for greenery. A minimum of 125trees per hectare should be planted. A minimum of 6.Om green belt should be

* developed around the PHC. All open spaces should be converted to garden withseating arrangements. Medicinal herbs, indigenous trees like Neem, Honge, flowering

* trees etc., should be planted around the premises. Dust bins should be provided at* vantage points to maintain a litter free enviroprpent.

PB-PKP/ Ver-3/04-10-05 Page * 37


xii. Noise reduction guidelines

A quiet environment in hospitals in desirable for patient who are acutely ill. The staffrequire quite conditions for consultation and examination and also in their living and

i sleeping quarters.

* The hospital sites with a high degree of sensitivity to outside noise should be as faraway from outside sources as may be compatible with other considerations, such as

* accessibility and availability of services. The building should be so arranged on thesite that the sensitive areas like wards, consulting and treatment rooms, operating

* theates an staff bed rooms are placed away from outdoor sources of noise, if possiblewith their windows overlooking areas of acoustic shadow.

* Since many components of the hospital design have an important bearing on theplanning of the common areas such as X ray departments, operating theatre units

* * and main kitchen, noise reduction in the sensitive areas should be weighed carefullyagainst other design factors. Special care in overall planning and internal planning

* against noise is required in the planning within the building of units which arethemselves potential noises source. For example, children's ward and outpatient

* ward, parts of which require protection against noise. Noise control is also difficultdue to the provision of hard washable surface which reflect and intensify the noise.Since most windows face the open external air, outdoor noise is also spread easily.

.Unloading bays, refuse disposal areas, boiler houses, workshops and laundry are

* examples o service units which should be far from sensitive areas of possible. TheKitchen is a constant source of both air borne an structure borne noise and should

* preferably be in a separate buildings, or screened from the sensitive areas, or placedbelow and not above wards and other sensitive rooms so as to facilitate insulation ofequipment an machinery to reduce the transmission of structure borne noise to a

* minimum.

* Use of resilient materials- mats of rubber or other resilient materials on drainingboard and rubber shod equipment will greatly educe noise from utility rooms, and

* ward kitchen. The use of plastics and similar material for sinks, draining boards,utensil and bowls reduce noise. Mobile equipment such as trolleys and beds may be

* silenced by means of rubber tyred wheels and rubber bumpers and provision ofresilient floor finish. The resilient floor also reduces footstep noise. Silent type curtain

* rails, rings and runners should be used. Lift gates and doors should be fitted withbuffers and silent closing gear. Fans and other machinery should be mounted onsuitable resilient mountings to prevent the spread of noise through the structure. The

* ventilation system should be designed so as not to create a noise problem. Silentclosers should be fitted to doors. The doors should themselves fit closely to the

* frames. Double doors provide very little insulation values and hence should have abackup arrangement

Many surface in hospitals should be easily cleanable so as to prevent build up of* bacteria which may cause cross infection. Most sound absorbent materials of soft* nature are difficult to clean and lose their effectiveness if painted for hygienic

reasons.

PB-PKP/ Ver-3/04-10-05 Page * 38


Some porous materials with very thin non porous coverings (like mineral wood* covered with thin plastic sheet) have good absorption an when covered with* perforated sheet metal facing can be used in most areas requiring a washable

acoustical treatment. In noisy areas, such as corridors and waiting rooms, however a* wider choice of absorbents is available.

* In the ward, bed curtains, window curtains etc., add to the absorbent properties ofthe room and help reverberation in other wise hard surfaced surroundings.

Sensitive areas such as operation theatres, Doctors consultation room, intensive care* units (ICU) require special consideration against noise control. To ensure silence a

sound reduction of 45 dB (A) between the rooms and waiting rooms shall be ensured.To obtain this level it is necessary to provide two doors separated by an air gap, such

* as a lobby or corridor.

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* Finial Report Karnataka Health, Nutrition & Population Project (KHNPP)

B. Construction stage Guidelines

* All construction activity should be as per the construction guidelines given inappendix C. xiv.

i. Debris & Dust control

Many of the building infrastructures related to the PHC and PHU are in dilapidatedstate. It is advisable to demolish the old structure and construct new facilities. The

* building area should be covered with tarpaulins supported on temporary scaffoldings.Water should be sprayed on the ground to suppress dust. This will control the dust

* spreading in the vicinity. Only controlled blasting carried out by a qualified personshould be allowed under exceptional circumstances. The construction debris should

* be dumped in only areas designated by the authorities. Renovation should be carriedonly on buildings certified by qualified engineers /competent authorities.

* C. Operation stage Guidelines

* ii. Water supply maintenance guidelines

* All the water tanks should e periodically cleaned. A record of such cleaning should bemaintained. Adequate provision should be made for such cleaning.

* A suggested method of controlling cleaning of water tanks

* Table - 10 Format for controlling of cleaning of water tanks

* Description of system Cleaned on Next cleaning due onWater tank 1 dd-mm-yyyy dd-mm-yyyyWater tank 2 dd-mm-yyyy dd-mm-yyyy

iii. Sewerage system maintenance guidelines0

The initial de-sludging period should at least once a year. Depending on the actual* usage pattern, this period may be increased to ensure proper working of the plant.

The overflow from the septic tank should be discharged into a soak pit/s of adequate* dimension which is determined by the characteristics of the soil at site. The septic

tanks should be provided with cast iron manholes of dimension 600 x 600 mm tofacilitate inspection and cleaning.

Table - 11 Format for controlling of de-sludging of septic tanks-

Description of system De-sludged on Next de-sludging dueon

Septic tank 1 dd-mm-yyyy dd-mm-yyyySeptic tank 2 dd-mm-yy dd-mm-yy

0

0

PB-PKP/ Ver-3/04-10-05 Page * 40

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* iv. Guidelines for managing waste in electrical and electronicequipment (WEEE)

-All electrical and electronic equipment which are condemned should be stored and

* sent for recycling, especially tube-lights and bulbs. Following procedure should beadopted in the health care setting.

* . A scrap committee / recycling committee should be formed in the PHC/PHU/SCEvery electrical/electronic part/equipment (including fuse, wires etc.) that is

* defunct, which is discarded should be listed in a separate inventory register forWEEE. This could be verified as every new replacement should have a waste.

* . After it is entered into the register, it should be stored in appropriatecardboard cartons and labelled as WEEE.

* . Depending on the quantity of this waste, it should be sold to a recycler.The proceeds from WEEE recycling could be used for gardening andlandscaping of the Health care setting.

v. Vehicle maintenance* The ambulances, project vehicles like jeep, car etc should be maintained in good

conditions. Regular checkup as recommended by the manufacturers should be* undertaken. Valid Pollution Under control (PUC) certificates has to be maintained for

each vehicle. Necessary budget head should be allocated for such an action.

A suggested format for ensuring control will be as follows:

* Table - 12 Format for vehicle maintenance

* SI.No. Vehicle Next PUC check Authorisedregistration maintenance due on service

* No due on centreAddress and

_____ _____ Tel.No.

vi. Measures for managing environmental impacts of campsCamps are conducted to increase the reach of health care facility among the needy.

* The health camp may be conducted at the hospital premises or at decentralisedlocations in the village. Different types of camps may be possible

* * Detection camp,. IEC camps

* . Immunisation camps. Surgery camps.

* Organising a camp at PHC/PHU has its own disadvantages and advantages. It causesa large scale congregation of people at the primary health care facility during theday. Besides disrupting the routine jobs, this leads to increased pollution due to

* movement of private vehicles such as 4 wheelers and two wheelers. Since the PHCsand PHUs are far away from the house, normally the patients are accompanied by

PB-PKP/ Ver-3/04-10-05 Page * 41

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! * Final Report Karnataka Health, Nutrition & Population Project (KHNPP)

their family or attendants causing higher stress on the water and sanitary facilities.

* Eating packed food shall cause increased generation of solid waste. However, theadvantages are complete control over the management and disposal of bio medicalwaste. This is a recommended method in the case of Surgery camps.

On the other hand, the advantages of a camp in villages is that the build up of people* is reduced. The stress on water and sanitation facility is also alleviated. People

normally eat at their residences and thus solid waste generation is also controlled.* Since the camp site is easily accessible vehicular pollution will be limited to that of

the vehicle transporting the medicals staff and equipment. Biomedical waste if any* such as swabs, sharps etc may be collected in bins and PPC and transported back to

the PHC/PHUs for safe disposal. This method is not recommended in camps where* there is a likelyhood of large generation of BMW waste. The camp should be* organised in buildings where adequate sanitary and water facilities are available to

prevent any outbreaks.

vii. Guidelines for Bio-medical waste management including* housekeeping within a PHC/PHU/SC

* All the waste generated in a healthcare setting should be segregated as per the Bio-* medical waste (management and handling) rules, 2000. The colour coding for

storage should be as per the rules (KHSDP manual on segregation and colour coding* to be provided to all the PHC/PHU). Other handling and management guidelines that

need to be followed are as given below:

. All dust bins should be made of good quality plastics and should not havegroves and markings. It should have smooth inner as well as outer surface -this is to avoid dirt sticking in the groves. No perforated dust bins should bepurchased

* . All dustbins should be lined with non-chlorinated plastic liners, which arecolour coded.

* * All the rooms should have minimum of one dust bin, depending on the typeof waste. In areas like nursing station, a set of dustbins for all types of waste

* generated should be placed.. Cleaning (sweeping and swabbing) should be undertaken twice daily and all

* the waste from the dustbins should be emptied twice a day.. Places like nursing station and laboratories, where infected wastes are

generated, 2% bleach solution (freshly prepared twice a day) should be

* added and the waste should be put in the solution.* The floors of the hospital should be first swabbed with a wet cloth (only

* water), then swept (to remove grits). This is done to avoid the dust (carryingpathogens) from rising into the air. Finally, it is swabbed with a disinfectant

* solution.. The swab cloth should be washed with detergent after every use.

* . The waste from every point should be emptied into colour coded drums andthen taken to appropriate disposal points.

. These drums should be closed* . The housekeeping personnel or ayahs and wardboys undertaking the

housekeeping should wear gloves, masks, aprons and proper footware.

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. They should be trained by the nursing staff and the doctor in charge on* handling and management of waste. In case they are found to be ignorant or

negligent, the doctor in charge and nursing staff should also be held* responsible.* . The quantity of waste in each of the drums (after collecting from the entire

PHC/PHU/SC) should be weighed along with the drum and a log should be* maintained. This should be undertaken twice a day.

. The personnel should wash their hands and feet with soap and disinfectant* solution after every cleaning schedule.

. The Operation Theatre (OT) should be fumigated before every operation* using formalin and potassium permanganate.

. Culture test should be done for the OT regularly (once after every fiveoperations).

* . Infected linen in the hospital should be double packed in plastic bags andtaken to the washing area and should be cleaned with bleach solution.

viii. Guidelines for disposal of bio-medical wastes in a PHC/PHU/SC* The segregated waste which are placed in the color coded drums should be taken to

the appropriate places for disposal as given below:

* . Sharps along with the sharps container after draining of the disinfectantshould be placed in the sharps pit and procedure given in appendix x should

* be followed.. Non-infected organic waste, like food waste should be put in the shallow pit

* (care should be taken to remove any plastics mixed in it). A layer of leaf litterand soil should be spread over the waste in the pit. Compost can be obtained

* from this pit which could be used for the garden. Non-infected recyclable material like plastic packaging material, paper and

* WEEE waste should be taken to the stores where recyclables are stored. Thisshould then be sent to the recyclers (refer WEEE management guidelines)

. Infected organic waste like swabs, body parts, body fluids, laboratory culture* media etc., should be taken to the deep burial pits and covered with a layer

of lime and soil kept handy next to the pit.* . Infected recyclables (like plastics and metals) should be disinfected using

bleach solution and then stored in the stores in drums which are covered.* They should be mutilated before sending for recyling.

. Placenta should be managed as per the guidelines given

ix. Guidelines for disposal of placenta in a PHC/PHU/SC

* Among all the waste disposed of, the placenta is a highly putrefyiable waste andcauses odor if not disposed properly. It is disposed off in trench burial pits. It is

* normally disposed of in deep burial pits as incinerator facilities are not available. In apit of 2.Om only 1.Om can be effectively used. Assuming that a 100mm thickness

* earth is placed on the waste, a deep burial pit could last for a maximum of 10 wastedisposals, or in other words a maximum of 10-14 deliveries. Thus a pit would last fora maximum of month in many cases.

At present, the pits are located within the hospital premises, normally in the farther* most corner and low lying area. The criteria of impermeable soil strata cannot be

* PB-PKP/ Ver-3/04-10-05 Page . 43

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I Inul ltReport Karniatdka liealthl, Nutrition & Population Project (KHNPP)

strictly adhered to. No additional lining is provided to alleviate this problem. The* need of placing a layer of earth each time a waste is placed is not followed strictly

and thereby causes foul odour. The trench method can prove to be a source of* contamination since there is a always a risk of flooding and contaminating the nearby

water sources.

* Alternatively, the septic tank may be an option for safe disposal of such placenta. Itis suggested that a exclusive water closet with a flush be provided at appropriate

* height in the labour rooms. The closet should be provided with a P or S trap toensure an effective water seal. The closet should be connected directly to the Septic

* tank and related tertiary treatment systems or other effective Decentralisedwastewater treatment plant with a slope higher than 1:60. The anaerobic

* decomposition will ensure the safe disposal of the placenta and also pathogen kill.

x. Guidelines on the use and disposal of sharps in a PHC/PHU/SC

Syrinaes and sharp maintenance:* a. The sharps (broken petri dishes, scalpels, blades, etc., which are potentially

contaminated with blood or body fluids) and syringes (broken glass syringes,* disposable syringes and needles) collected in the puncture proof containers

have to be disposed of in the sharp pit after removing them from the PunctureProof Container (PPC).

* b. The PPC along with the sharps should be placed directly in the sharp pit, so asto avoid contaminating the soil. As no handling of sharps is involved, it helps in

* preventing secondary infections and serves as a convenient way of controllingand ensuring that the sharps are disposed safely. The PPC after draining may

* be weighed to get a record of number of syringes it contains which may beuseful in cross checking with actual consumptions.

Guidelines for glass syringes use:The treatment and sterilisation problems of glass syringes could be overcome by the

* following simple techniques:

v o The best alternative to disposable syringes is to use glass syringes after it issterilised and can be reused. The issue of sterilisation can be ensured by using

* autoclaves operated by electricity or gas as backup.o Every institution should be provided with at least double the average number

* of syringes used in a day.* o For every 30 syringes used per day in an institution, one autoclave of 15 litre

capacity should be provided. One gas operated autoclave of equivalent* capacity should also be provided as a backup. Each autoclave should be

provided with two numbers of compatible steel bins with lids.* o The bin from the autoclave should be taken out and kept at the nursing station

with its lids closed. Tongs should also be sterilised and should remain in the* bin for use repeatedly.

o The syringes should be removed from the bin using the tong and the tong* should be replaced back into the bin immediately.* O The used syringes should be placed in a separate steel bin and at the close of

the day, should be sent for sterilisation. This will avoid multiple handling of the* used syringes.

PB-PKP/ Ver-3/04-10-05 Page + 44


o However, in places where hard water is found, scaling can occur and the glass* syringes will be non-functional. In such cases mineral water/distilled water

supply should be made.

* Disposable syringes could be used in immunisation camps since it will be difficult toensure the minimum sterilisation time. The possibility of procuring required numbers

* of glass syringes could also be explored as it could be taken back, sterilized andreused in other camps, which is more environment friendly. However, reuse of glass

* syringe after sterilising at the camp should not be encouraged.

* xi. Terms of reference for the periodic internal and externalenvironmental monitoring review

* Internal environmental reviewSampling: A minimum of 10% of each type of health care has to be audited on a

* quarterly basis. The facility to be audited has to be chosen randomly from the masterlist of PHC, PHU and Sub Centre. A table of three digit random numbers should be

* used to select the facility.

* Duration of audit: The duration of audit should be one day.

Auditees: Medical Officers, Nursing staff, Dispensing staff, WM staff and the* designated environmental in-charge

* Resources required: A helper, weighing machine, camera, sampling bags, transportvehicles

External environmental reviewSampling: A minimum of 2% of each type of health care in the state has to be

* audited once in six months. The facility to be audited has to be chosen randomlyfrom the master list of PHC, PHU and Sub Centre. A table of four digit random

* numbers should be used to select the facility.

* Duration of audit: The duration of audit should be one day.

* Auditees: Medical Officers, Nursing staff, Dispensing staff, WM staff and thedesignated environmental in-charge

Resources required: Environmental head of district, 2 helper, weighing machine,Video and still camera, sampling bags, transport vehicles,

xii. Other environmental monitoring activities for a PHC

Water quality monitoring

Water quality should be monitored in open wells and drinking water sources locatedwithin 100m radius from the facility. The data should be analysed for any deviations

i and furnished to the DHOs office for records. This data should be used for supplyingmineral water or distilled water for sterilisation of syringes depending on the

* brackishness.

PB-PKP/ Ver-3/04-10-05 Page + 45

: Final Report Karnataka Health, Nutrition & Population Project (KHNPP)

xiii. PMP with regards to DDT usage in the institutions* Since the Bank's environmental safeguard policy OP 4.09 is triggered, measures to

counter the bad practice of usage of DDT will be taken into consideration in thisproject. The following guidelines will be practiced:

* Biological control of mosquitoes will be resorted to wherever possible. For* example introducing Gambusia fish in lakes and ponds. This will help in

control of vectors of Malaria disease.* . In drains and other shallow stagnant water sources, DDT could be used

until an alternative exists.* . In order to avoid misuse of DDT, a proper inventory control will be

established.o The present system existing will be reviewed and stock checks

* carried out.o KANBAN system of inventory control should be used, wherein each

* institution will have only the required amount of DDT for the month.While indenting for the next batch, a complete location wise usage

* list should be provided. This has to be verified and counter signed bythe DHO.

o In case of misuse noticed, disciplinary actions will be initiated againstthe Doctor-in-charge of the PHU/PHC.

xiv. List of references for Planning and Construction* a. National building code of India 1983

b. Basic requirements for drainage and sanitation- IS 1172-1983* c. Code of practice for water supply in buildings Is 2065 -1983

d. Code of practice for installation of septic tank - IS 2470* e. Code of practice for building drainage - IS 1742 -1983* f. Guide lines for planning and design of surface drains - IS 8835-1978

g. Laying of water and sewer lines including appurtenant items - IS 1200

D. List of special studies

i. Pesticides and ODS in Health Programmes (current status & projectinterventions) with emphasis on DDT

During the course of the field visits it was noticed that some of the PHCs were* misusing the DDT supplied to them for Malaria Control. The study also revealed that

there is no proper inventorisation maintained for the insecticides and other harmful* chemicals/disinfectants used. Hence, a study which would suggest an implementation

plan to manage Persistent Organic Pollutants and Ozone Depleting Substances inHealth Programmes needs to be undertaken before the implementation of the

* KHNPP. Following aspects needs to be covered in the study:

* a Health Programmes/activities which utilise POPs- especially pesticides, ODSand Toxic chemicals. Quantities used, frequency of use, the supply chain etc.,

* " Mode of disposal of the used containers, leftovers, expired chemicalsAwareness levels of the personnel handling the chemicals, occupational

* hazards

PB-PKP/ Ver-3/04-10-05 Page * 46


* Suggest methods of inventory control* * Suggest methods for alternatives to be used

* Suggest methods for reduction of POPS, ODS and toxic chemicals* * Monitoring and evaluation mechanism* * Record maintenance formats

* Safety measures and training requirements

ii. Environment Training Needs Assessment (ETNA) study

The EA study revealed that most of the environment problems in the institutions are* due to lack of awareness. A detailed ETNA study is required to draw up a training

schedule to tackle this problem. The TOR for this study should consist of thefollowing:

* Categories/levels of staff. Number of personnel in each category* * Determine the job profiles of each category of personnel

* Conduct a preliminary awareness level survey through questionnaires* a Identify type of training required based on their job requirement

a Design a training module for each category* * Prepare a training schedule for each category

* Determine the budgetary requirement* Suggest suitable trainers

* * Develop suitable feed back and evaluation mechanisms to determine theeffectiveness of training imparted

iii. Adequacy and Need Assessment of Infrastructure for Environmental* Management

* The EA study revealed that most of the infrastructure provided for the institutions* was not adequate and appropriate. Although broad siting and building guidelines

have been provided in this report, specific districts have specific requirements as far* as infrastructure is concerned as certain unique environment characteristics are

present. Hence, a need assessment study for infrastructure for environment* management is essential. The TOR for the study should contain the following

aspects:

* Study the siting and locational aspects of the institutions district wise* Determine the infrastructural requirements like BMWM structures, its capacity,

* ideal location etc.,* Prepare layout plans for the selected institutions

* * Prepare guidelines for implementation* Determine approximate budgetary provisions required

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PB-PKP/ Ver-3/04-10-05 Page * 47

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Action taken on comments from the Safeguard Review - Environment - EA & EMP reports

SLNo. I Comments Clarification Action takenReviewer l's comments

1. The EMP covers all the main This EMP is annexed toissues and includes some PIP and separateuseful guidance but is a little guidelines are providedunclear on integration with the to help integrate this toproject as a whole and with ICF and PHF. Detailsthe operation of the DoHFW. given in Appendices - A

_ _ (i) ~~~~~and (ii)2. There will be a new wing SNOE will sit in A revised organisational chart

established for the project KHSDRP office, and explanation is provided(KHNPP), within which there Bangalore in EMP report chapter 4 pagewill be a State Nodal Officer numbers 6 & 7Environment (SNOE) at JointDirector level, and belowhim/her the EMP will beimplemented through theDHO staff. However, it is notclear where the SNOE sitswithin the KHNPP structure.Ideally, the SNOE would bepart of the overall healthsystem "Quality Improvement"or "Quality Control" system sothat it is fully mainstreamedand can help to enhance thedesign of PHC and also theoperation of the system andtraining and staffdevelopment. Such a structurewould also provide a naturalsynergy with whatever reviewand monitoring systemsKHNPP will establish for theperformance and effectivenessof the PHCs (etc) and sowould make monitoring ofenvironmental and socialissues much morestraightforward.

3. The recommendation in It is mandatory The EMP report clearly statesSection 6.8 of a daily log of according to BMWM the mandatory requirementbio-medical waste is Rules, 2000 under chapter 6.8 pageunrealistic unless it can be number 16integrated into more generalPHC operational practice

4. Reporting structure for the See point number 2l_____ SNOE and related

SLNo. Comments Clarification Action takenorganisational aspects shouldbe clarified during apprai-salI

5. There is a training program Training plan is laid out This is stated in the chapter 5laid out, at least for 2005 with regard to topics page 9 parah 3 to avoid(assumed to be but the modules ambiguity"Year 1"of implementation). necessary is not knownThis program is unrealistic, as detailed TNA was notgiven that it is recommended undertaken. Hence,that a specific Training Policy TNA is to determine thewill need to be developed modules for each target(which I completely support). group.There is no indication whetherthe training can build directlyon existing activities (underthe previous project, perhaps?)I suggest that the schedule bereviewed to (i) allow for theformulation and approval ofthe Training Policy; (ii) ensurethe availability of appropriatetraining material and trainers(does this have to be preparedor contracted?) (iii) beintegrated with other trainingprograms for the same staffand (iv) be consistent with thephysical upgrading program.The training timetable shouldbe reviewed during appraisaland a more realistic timeprogram outlined (with detailsto be developed duringimplementation).

6. The budget costs appear to The budget is integrated A note is added in the Budgetcover the main items for a with PIP costs. It will be Chapter - 9 page 22typical PHC and now need to checked duringbe aggregated or extrapolated appraisalso that the overall costs to theKHNPP of the proposedmeasure can be estimated andallowance made in the projectcosts estimates. The overallcosts of implementing theEMP should be estimated atappraisal and suitableallowance made in the projectcosts. I note that the salary ofthe SNOE is included as aproject cost. This again raises

SLNo. Comments Clarification Action takenthe question of the integrationof this position intoDoHFW/KHNPP. Is this agovernment position or a fixed

I term project position?Reviewer 2's comments

7. In the EA, the applicability of Since no PMP exists a A new appendix C, xiii isthe Bank's environmental study is suggested. added in page 46safeguard policies has been However a separateanalyzed and OP 4.01 & OP annexure to take care of4.09 has been triggered. It is the DDT misuse addedstated that an EnvironmentalManagement Plan / EMP (tomeet requirements of OP 4.01)and Pest Management Plan /PMP (to meet requirements ofOP 4.09) are necessary.Whereas an EMP has beendeveloped, a PMP has notbeen included. Given thelimited relevance of the PMPin this project, this is bestincluded as another separateguideline in the EMP so that itis ensured that pesticides arenot used in applications forwhich it is banned. In otherwords, pesticides such as DDTshould be used solely formalaria control, which is apermitted application.

8. In the EA, it is stated that the It is clearly stated. There To make it clear a note isprocedural requirements of the are four appendices C added stating that it is as perIndian legislation - Biomedical vii, viii, ix and x are BMWM Rules and the KHSDPWaste Management Rules - dedicated to this. manual on BMWM will behas to be followed. provided to all theBut this has not been covered PHC/ PHU, which has theadequately / explicitly in the details on segregation andEMP. This should be done so colour coding. Page 42as to ensure itsimplementation

9. Organizational capacity- Posts are already filledbuilding has been given its up.due focus. At the statelevel, two officers - a nodalofficer and a deputy nodalofficer(*) - have beenproposed. It is important thatthese nodal EnvironmentalOfficers are in position by _

SLNo. Comments Clarification Action takenproject negotiationspreferably) and projecteffectiveness(definitely). This is particularlyimportant considering that theGovernment officer, who co-ordinated the preparation ofthe EA & EMP, is no longerwith the project team. Areplacement should be foundat the every earliest. ThisShould be made an explicitcondition so that the project'stop & senior management takedue cognizance. [* In someparts of the EMP, it isindicated that there is only onestate-level officer. This shouldbe consistent.]

10. The proposed budget needs to Reviewed in detail. A See point number 6.be reviewed in detail and also separate meeting withhas to be integrated with the the Engineering wingbudget for the rest of the executing the projectproject was also undertaken.

Documents

World Bank Document · PDF fileOrganisational structure ... Environment Training Needs Assessment (ETNA) study .47 * iii. ... Final Report Karnataka Health,