Brazil: Family Health 2 Project APL Phase 2 (PROESF 2) Environmental Framework

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized 1. Introduction Brazil: Family Health 2 Project APL Phase 2 (PROESF 2) Environmental Framework This Environmental Assessment (EA) was prepared for the purposes of identifying potential environmental impacts in compliance with World Bank Safeguard Policy (OP/BP 4.01). This summary identifies potential risk, proposes measures to promote positive environmental impacts as well as to mitigate potential adverse impacts generated by the Family Health Extension 2 Project (PROESF 2). This summary focuses on two areas with potential impacts. The first concerns new construction and rehabilitation of ambulatory health units. The second involves the implementation of an effective waste management system in these as well as other ambulatory units receiving project financing. The Project EA is based on: (i) an analysis of the legal and regulatory framework for health facility construction and medical waste management; (ii) review of guidelines and procedures with respect to ambulatory unit construction and medical waste management; (iii) meetings with MOH and project personnel responsible for PSF and project implementation; and (iv) an in-depth environmental assessment of PSF performed by the Pan American Health Organization in preparation for APL Phase 1 of the PSF. The proposed project has potential for generating both positive and negative environmental impacts. The negative impacts could result from expansion of the system of basic health units. At the same time, however, the project has enormous potential for producing positive impacts. This is evident in the very concept of the project moving health teams into local communities, and identifying and addressing environmental factors that could threaten the health of the population. This effort will reduce the environmental degradation in these communities. PROESF 2 will construct new but small-scale ambulatory units on public land in high density areas of large urban cities. Building area will range from 100 to 300 m 2. 1 Based on a preliminary needs assessment, the MOH estimates that approximately 230 units will be constructed in the 187 participating municipalities. 2 Construction will not take place in protected areas or on ecologically fragile sites. Nor will construction result in involuntary resettlement. 2. Safeguard Policies E1600 OP 4.01 Environmental Assessment: This project was classified as Category B due to the proposed financing of new construction. Following Bank policy, an Environmental Impact Assessment (EA) was performed and an Environmental Framework (EF) was prepared to guide selection, screening, construction and monitoring of new health unit construction. The EF specifies specific measures by which the project will mitigate environmental risks, including: (i) an environmental screening and monitoring of construction sites; (ii) environmental licensing of all construction; (iii) environmental supervision of construction process; (iv) development and implementation of medical waste training program to improve medical waste management 1 Size will depend on the number of PSF teams occupying the building. Nearly all units house between one or three teams. Cost will vary from R$800 to R$1200 per m2 depending on local construction costs. 2 A list of the number of new constructions per municipality is available in the project files.

2 system; and (v) MOH and Bank supervision of the medical waste management system in family health units. OP. 412: Involuntary Resettlement: The project will not finance activities that may lead to involuntary resettlement (physical relocation, loss of assets or access to assets). However, since the project finances new construction, the policy could be triggered through land acquisitions for construction purposes. Although all sites will be located on public lands, the Operational Manual will stipulate that any new construction that may result in resettlement will not be eligible to receive funding. 3. Overall Environmental Impacts The EA analyzed potential impacts of new construction, both positive and negative. In general, any adverse impacts are expected to be localized and reversible. However, the improvement of medical waste management in ambulatory health units will have beneficial environmental impacts. During unit construction, the impacts would generally be temporary, of low intensity and with well-known mitigation measures that can be easily implemented. Negative impacts could results from inadequate site selection, terrain movements, dust and noise contamination of superficial water supplies and inadequate disposal of garbage and construction waste. However, the potential impact is low because all works are small scale. Nevertheless, environmental guidelines that are aligned with Brazilian legislation as well as MOH basic unit construction guidelines (see below) will be included in the Operational Manual. During facility operation the main possible internal negative impacts are related to inadequate management and disposal of medical waste generated from patient diagnosis and care. This would pose a safety threat to both patients and employees. This risk will be mitigated through strengthening the system for management and disposal of medical wastes, per government environmental regulations and MOH guidelines. Other external negative impacts are related mainly to waste generation and atmospheric pollution generated from equipment, sewage treatment and disposal, and treatment and removal of non-medical solid waste. These issues will mitigated through implementing in all health units benefiting from project financing MOH s hospital environmental safety and MOH/ANVISA s Manual for Medical Waste Management guidelines. The guidelines deal with each of the above mentioned issues. 4. Regulatory Framework and Construction Guidelines The health sector possesses a vigorous legal and regulation framework related to facility construction. The legal and regulatory framework has been strengthened in recent years through the issuing of regulations of more detailed regulations and guidelines governing medical waste management and health facility construction (in 2004 and 2005). More recently (in 2006) the MOH produced basic health unit construction guidelines based on current legislation. Participating municipalities will follow the guidelines in the planning, construction and operation of new facilities. The project s environmental framework is based on the following regulatory and institutional instruments: Medical Waste Management National Environmental Board (CONAMA) 283/01 (2001): Stipulates general procedures for the management and disposal of medical waste in health facilities. Mandates the preparation of a Management Plan for Medical Waste in Health Facilities.

3 ANVISA 306/04 (2004) and CONAMA 385/05 (2005): These instruments: (i) set a single and integrated regulatory framework for management of medical waste generated in health facilities, including separation, storage, transport, treatment and final disposal; (ii) mandate the development and implementation of Management Plan for Medical Waste in all health facilities. ANVISA/MOH Guidelines (Manual for Medical Waste Management, 2004): This manual provides detailed guidelines to local system and facility managers regarding the implementation of the above mentioned regulations including the development and execution of a Management Plan for Medical Waste in all health facilities. 3 Building Codes for Health Facilities Federal Law 6.437/77 (1977): This law represents the basic sanitary legislation and mandates the essential structural features of health facilities according to type (hospital, diagnostic center, basic care unit, etc.). All health facilities are required to be licensed according to this law. National Agency for Sanitary Control (ANVISA) RDC 50/02 (2002). Drawing on Law 6.437/77 this is the guiding regulatory instrument for new buildings, rehabilitations, and expansions of health units. It details norms regarding potable water, electricity, collection and disposal of sewage, solid and medical waste disposal, etc. CONAMA no. 297/97: Regulates the criteria and processes to obtain an environmental license, requiring an environmental assessment and local consultations. MOH Guidelines (Manual for Physical Infrastructure for Basic Care Units, 2006). Drawing on the above regulations, this user-friendly manual provides detailed guidance on physical space (including architectural plans), equipment specifications, content of solid and medical waste management, etc. for basic care units. The manual was prepared in anticipation of new constructions that would be financed by the proposed project. Most if not all the participating municipalities will follow the guidelines upon planning, designing, constructing and operating new units. 5. Consultations The Unified Health System (SUS) is built upon consensus among health authorities, civil society and communities. An essential part of its structure is a set of formalized forums to discuss policies, plans and initiatives at all levels of government. Health Councils consisting of representatives of civil society (universities, non-profit health organizations, NGOs and women groups) are legally mandated in each sub-national government. The PROESF 2 project together with its implementation plan, including new constructions, will be debated and approved by the Municipal Health Councils in each of the 187 participating municipalities. The PCU will not approve any plan until evidence is presented of consultations with and approval by civil society organizations and any affected communities. 3 The MOH has also developed a course (and CD) on developing and implementing Medical Waste Management plan in basic care units. The course is based on implementation in a hypothetical basic care unit.

4 6. Environmental Framework (to be included in the Operational Manual) Proposed Procedures by Project Phase to Mitigate Potential Environment Risks Related to Construction of Basic Health Care Units. Major Activities Functional Analysis and Site Selection Stage Functional analysis will: (i) assess accessibility of targeted population (traffic patterns, bus routes, etc.); (ii) establish the characteristics of the spaces according to the number of PSF teams and planned activities in the building; (iii) verify public land ownership; (iv) assess soil and subsoil conditions of potential sites and their vulnerability to land slides, flash floods, natural disasters, etc. (v) assess site for contamination and from contaminated sites such as stagnant water, open sewers, polluted bodies of water; (vi) define specific spaces, activities, and basic equipment; (vii) integration of building into architectural style of surrounding neighborhood; and (viii) review national and local laws, regulations, building codes and guidelines that will be considered in design, construction and operation of the facility. Based on the above, the local team prepares a Works Implementation Plan for the design and construction of the unit. Engineering designs and technical specifications to consider (i) connections to electric, water, sewerage network; (ii) water filtering system [potable water]; (iii) treatment of wastewater; (iv) systems for collection, separation, storage and transport of wastes (medical and non-medical); (v) spaces and access points for pedestrians, disabled persons and vehicles; (vi) emergency access points (if necessary); (vii) avoidance of toxic materials such as asbestos, lead-based paints, etc. and (viii) avoidance of non-certified wood. Designs will follow MOH norms specified in Manual for Construction of Basic Care Units Design Specific Environmental and Safeguard Measures Conduct assessment of potential environmental impacts of proposed site, including endogenous and exogenous factors, according to CONAMA 237/97 and MOH Basic Care Unit Construction Manual Prepare plan and process to secure compliance with CONAMA 237/97 environmental regulations Conduct consultations with communities and representatives of civil society in the affected areas. Verify that site will not involve involuntary resettlement Verify that site is not located in protected area or one with fragile environment Ensure design complies with ANVISA, RDC 50/02 and local or national environmental protection regulations such as CONAMA 237/97 Secure sanitary and environmental permits to construct on selected sites. Develop Works Supervision Plan (draft framework plan included in EF) to ensure that contractor is following design and technical specifications and following environmental regulations and guidelines. Prepare terms of reference for contractors specifying that they are required to following environmental and sanitary regulations and that construction process will not adversely affect the surrounding vegetation, infrastructure, water and electrical connections. Construction Includes construction and procurement of materials Implement Works Supervision Plan to ensure compliance with sanitary and environmental norms and MOH Construction Manual Sanitary inspection is conducted by appropriate agency and specialists Secure sanitary/operating license (prior to operation)

5 Once operating and environmental licenses obtained, the facility commences operations according to PSF program specifications (these are summarized MOH Construction Manual), including (i) provisions in place for equipment and plant maintenance; and (ii) implementation of solid and medical waste management system. Operation Environmental inspection is conducted by appropriate agency and specialists Secure environmental license (prior to operation) Develop and Implement Medical Waste Management Plan based on ANVISA s Manual for Medical Waste Management and MOH s Hospital Environmental Guidelines, including processes classification of wastes, separation, storage, treatment and final disposal. The Plan should specify the following: (i) Application of environmental monitoring checklist 4 to obtain baseline and follow-up data on environmental situation of unit (EF contains model instrument); (ii) development and implement training program on management and disposal of medical wastes (EF contains course recommendations; 5 and (iii) supervision plan to verify compliance with medical waste regulations and implementation of Medical Waste Management Plan. MOH and Bank supervisory visits will include site visits to monitor implementation of Medical Waste Management Plan. 4 The environmental checklist to monitor implementation of medical waste mitigation measures is included in the project s M&E framework. See Annex 3. 5 Training program will be financed through Project financing.

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