Ghana - Second Health Sector Program Support Center : environmental assessment

E646 MINISTRY OF HEALTH(MOH) REPUBLIC OF GHANA ENVIRONMENTAL ASSESSMENT OF THE SECOND PHASE OF THE MEDIUM TERM HEALTH STRATEGY (MTHS) AND FIVE YEAR PROGRAMME OF WORK (5YR POW)-2002-2006 ENVIRONMENTAL ASSESSMENT DRAFT FINAL REPORT VOLUME ONE (1) SEPTEMBER, 2002  Environmental Analvsis of the Second Phase of the MITHS-5YRPOW(2002-2006) TABLE OF CONTENTS ACRONYMS ....................8 EXECUTIVE SUMMARY . . .. .................................................... 10 1.0 INTRODUCTION ..20 1.1 BACKGROUND .20 1.2 PURPOSE AND OBJECTIVES OF STUDY .21 1.3 SCOPE OF WORK .22 1.4 FIELD WORK .23 2.0 DESCRIPTION OF THE PROPOSED PROGRAMME .26 2.1 PRIORITIES OF THE PROGRAMME .26 2.2 SCOPE OF THE HEALTH SECTOR ....................... 27 3.0 DESCRIPTION OF THE AREA OF INFLUENCE .28 3.1 PROGRAMME CATEGORIES AND LOCATIONS . .28 3.2 ExISTING FACILITIES WITHIN THE HEALTH SECTOR . .35 3.3 DISTRIBUTION OF FACILITIES ..36 3.4 TYPES OF UNDERTAKINGS AND DEFINITIONS . .36 3.4. 1 Sub-District Level Facilities ................... 36 3.4.2 Out-Patient Clinics. 37 3.4.3 Small In-Patient Clinics/Hospitals. 37 3.4.4 District Hospitals .38 3.4.5 Regional Hospitals .39 3.4.6 Teaching Hospitals .40 3.4.7 MASTERPLAN FOR THE EXPANSION PROGRAMME / COMPENSATION PLAN ... 41 3.5 POTENTIAL STAKEHOLDERS ......................................................... 42 3.6 HEALTH-CARE WASTE GENERATION AND MANAGEMENT PRACTICES ... 43 3.6.1 Solid Waste ....................... 43 3.6.2 Liquid Wastes .44 3.6.3 Air Emissions .44 3.7 CLASSIFICATION OF WASTES ..44 3.8 SEGREGATION OF WASTE ..47 3.8.1 Solid Wastes. 47 3.9 TREATMENT OF WASTE ..48 3.9.1 Chemical Dis-infection .............. 48 3.9.2 Sterilisation ...... 48 3.10.2 Incineration ...... 48 3.10.3 Disposal at Dumping Grounds through Municipal Authorities ............... 48 3  Environmental Analvsis of the Second Phase of the MTHS-5 )'RPOW(2002-2006) 3.10.4 Disposal of Liquid Waste ......................................49 3.11.2 Water and Groundwater Contamination ..........................49 3.11.3 Contamination of Handlers.....................................49 3.12 Impregnation and Re-Impregnation of Bednets .......................49 3.12.1 Effects of Deltamethrin on Humans and the Environment.............50 4.0 DESCR IPTION OF LEGAL,REGULATORY, AND ADMINISTRATIVE FRAMEWORKS..................................................53 4.1 HEALTHY PUBLIC POLICY ..........................................53 4.2 LEGAL PROVISIONS ...............................................53 4.3 INSTITUTIONAL FRAMEWORK .......................................54 4.4 RELEVANT LEGISLATION ENACTED ..................................54 4.5 RESPONSIBILITY FOR MANAGEMENT OF HEALTH-CARE WASTE .............55 4.6 GENERAL OVERVIEW OF HEALTH-CARE WASTE MANAGEMENT PROCESS......55 5.0 METHODS AND TECHNIQUES USED IN ASSESSING AND ANALYSING THE IMPACTS ......................................56 5.1 METHODOLOGY..................................................56 5.1.1 Restatement of major environmental analysis objective................56 5.1.2 Environmental Analysis Design..................................56 5. 1.3 Key Variables and Concepts ....................................56 5..1.4 Relationship between Variables..................................57 5.1.5 Sampling Design and Procedures ................................59 5.1.5.1 Geographical Dimension of study population. ...................59 5.1.5.2 Instruments, tools for measuring variables and questionnaires .......59 6.0 CONSULTATIONS WITH PEOPLE AFFECTED BY THE PROPOSED PROJECT .......................................................60 6.1 MINISTRY OF HEALTH .............................................60 6.2 MINISTRY OF LANDS AND FORESTRY..................................60 6. 3 THE MINISTRY OF LOCAL GoVERNMENT AND RURAL DEVELOPMVENT ........60 6.4 LANDS COMMISSION ..............................................60 6.5 LANDS VALUATION BOARD.........................................6 1 6.6 ENVIRONMENTAL PROTECTION AGENCY...............................6 1 6.7 HEALTH INSTITUTIONS.............................................6 1 6.8 METROPOLITAN AUTHORITIES & DISTRICT HEALTH ADMINISTRATIONS ......62 7.1 PRE-CONSTRUCTIONAL PHASE IMPACTS ...............................63 7.2 CONSTRUCTIONAL PHASE IMPACTS...................................63 7.2.1 Safe ty.......................................................63 7.2.2 Dust generation / Air pollution ..................................63 7.2.3 Noise.......................................................63 7.2.4 Waste ......................................................63 7.2.5 Vegetation, fauna and flora loss..................................64 7.3 POTENTIAL IMPACTS OF HEALTH-CARE WASTE..........................64 7.3.1 Types of Hazards..............................................64 7.3.2 Persons at Risk...............................................64 7.3.3 Hazards from infectious waste and sharps ........................64 7.3.4 Hazards from Chemical and Pharmaceuitical waste..................66 4  Environmental Analysis of the Second Phase of the MTHS-5YRPOW(2002-2006) 7.3.5 Hazards from Genotoxic Waste ..................................... ................. 67 7.3.6 Hazards from Radioactive Waste ....................................................... 67 7.3. 7 Public Sensitivity ...................................................... 67 7.4 PUBLIC HEALTH IMPACT OF HEALTH-CARE WASTE .......................................... 68 7.4.1 Impacts of Infectious Waste and Sharps . . .68 7.4.2 Impacts of Chemical and Pharmaceutical Waste . . .68 7.4.3 Impacts of Genotoxic Waste . . .68 7.4.4 Impacts of Radioactive Waste . . .68 7.4.5 Soil Contamination and Groundwater Pollution . . .68 7.4.6 Impact of Wastewater Disposal . . .69 7.4.7 Air Emissions . . .69 7.5 SOCIAL IMPACTS ....................................................... 69 7.5.1 Removal of geographical inequalities ...................................................... 69 7.5.1.1 Improving Geographical Access ........................................................ 69 7.5.1.2 Improving Financial Access ........................................................ 70 7.5.1.3 Improving Socio-cultural Access ......................................................... 70 7.5.2 Improving Efficiency ....................................................... 70 7.5.2.1 Improving Cost Effectiveness ........................................................ 70 7.5.2.2 Improving Planning, Management, and Administration . . 70 7.5.3 Fostering Partnerships ........................................................ 71 7.5.3.1 Improving Partnerships with Households and Communities ............... 71 7.5.3.2 Improving Partnerships between Private and Public Sector Providers. 71 7.5.3.3 Improving Partnerships with other Ministries, Departments and Agencies (MDAs) ......................................................... 71 7.5.4 Improving Equity in Financing ......................................................... 71 7.5.4.1 Reducing the Budgetary Burden of Health-care for Poor People ......... 71 7.5.4.2 Increasing Public Expenditure on the Poor and Vulnerable .. 72 7.5.5 Increase in Household Resources ......................................................... 72 7.5.7 REVIEW OF GHANA'S LAND POLICY ................................................... 76 8.0 ANALYSIS OF ALTERNATIVES .77 8.1 ANALYSIS OF ALTERNATIVES TO ACHIEVING IMPROVED HEALTH . . 77 8.2 ANALYSIS OF WASTE MANAGEMENT ALTERNATIVES ....................................... 77 8.2.1 Treatment And Disposal ................................................. 77 8.2.2 Treatment Options ................................................. 77 8.3 DISPOSAL OPTIONS ........ ............... .......................... 82 8.3.1 Control Disposal at Sanitary landfill ................................................. 82 8.3.2 Landfilling in Mdunicipal Disposal Sites ................................................. 82 8.3.3 Safe Burial On Hospital Premises ...................................... ............ 83 8.4 WASTE MINIMISATION OPTIONS ........................................... 85 8.5 WASTEWATER TREATMENT AND DISPOSAL .................................................. 87 8.5.1 Connection to a municipal sewage treatment plant without any pre- treatment .... 88 8.5.2 On-site treatment or pre-treatment of wastewater .88 8.5.3 Minimal Safety Requirements .88 5  Environmental Analysis of tle Second Plase of the MTHS-5YRPOW029O2-2006) 9.0 PROPOSED ENVIRONMENTAL AND SOCIAL IMPACTS MITIGATION MEASURES ............................................................... 90 9.1 POLICY INITIATIVES .............................0.................................. g 9.1.1 Completion of Health-care waste Guideline . ............................................ 90 9.1.2 Development of Health-Care Waste Management Policy ........................ 91 9.1.3 Collaboration with HIVAIDS Project on Waste Management ... 92 9.2 WASTE MANAGEMENT ............................................................... 92 9.2.1 Waste Segregation and Packaging ........................................................... 92 9.2.2 Storage ................................................................ 94 9.2.2.1 Internal Storage .................... ........................................... 94 9.2.2.2 External Storage ............................................................... 95 9.2.3 General Requirements For Waste Collection Containers ... 96 9.2.4 Transport Of Health-care wastes . . .96 9.2.5 Treatment and Disposal Technologies . . .97 9.2.5.1 Disposal at Sanitary landfill .99 9.2.5.2 Landfilling in Municipal Disposal Sites ........................... 99 9.2.5.3 Collection and Disposal of Wastewater . . .99 9.2.5.4 Disposal at Sanitary landfill .100 9.2.5.5 Safe Burial On Hospital Premises .101 9.2.5.6 Collection and Disposal of Wastewater .101 9.2.6 Preparation of Waste Management Plans .101 9.3 SOCIAL IMPACTS MITIGATION MEASURES . . .102 9.4 ESTIMATED COSTS OF PROPOSED MITIGATION MEASURES ... 104 10.0 PROPOSED INSTITUTIONAL FRAMEWORK FOR ENVIRONMENTAL MANAGEMENT .106 1 0.1 INSTITUTION OF A NATIONAL CAPACITY BUILDING PROGRAMME .106 10.1.1 Target Trinees .106 10.1.2 Training/Capacity Building Program Content .106 10.1.3 Training/Capacity Building Responsibilities . 07 10.2 MANAGEMENT RESPONSIBILITIES ..107 10.2.1 AIanagement Structre .108 10.3 HEALTH-CARE WASTE ENVIRONMENTAL MANAGEMENT COMMITTEE . 109 10.4 ENVIRONMENTAL MANAGEMENT SYSTEMS . 110 11.0 MONITORING INDICATORS .112 11.1 INTERNAL PACKAGING AND STORAGE .112 11.2 EXTERNAL PACKAGING AND STORAGE .112 11.3 TRANSPORTATION .113 11.4 TREATMENT AND DISPOSAL. 13 11.5 ADMINISTRATION . 113 12.0 MONITORING PLAN .114 13.0 RECOMMENDATIONS .115 13.9 RECOMMENDATION FOR IMPREGNATION OF BED NETS .118 6  Environmental Analysis of the Second Phase of the MTHS-5YRPOW(2002-2006) 14.0 LIST OF INDIVIDUALS/INSTITUTIONS CONTACTED .................... 119 15.0 REFERENCES .120 16.0 ANNEXES .121 16.1 ANNEX 1: TERMS OF REFERENCE ......................... .... ..... 121 16.2 VOLUME 2: RESETTLEMENT POLICY FRAMEWORK .......................1....... 23 7  Environmental Anavsis of the Second Phase of the MTHS-5YRPOW(2002-2006) ACRONYMS AIDS Acquired Immuno Deficiency Syndrome BMC Budget Management Centre BOD Biochemical Oxygen Demand CD Communicable Disease CMS Central Medical Stores CR Central Region CSM Cerebrospinal Meningitis DA District Assembly DANIDA Danish International Development Assistance DFID Department for International Development DH District Hospital DHA District Health Administration DHMT District Health Management Team EA Environmental Assessment EIA Environmental Impact Assessment EMU Estate Management Unit EHU Environmental Health Unit EPA Envirornmental Protection Agency EPI Expanded Programme Immunisation GHS Ghana Health Service GMA Ghana Medical Association GPRS Ghana Poverty Reduction Strategy GOG Government of Ghana HIV Human Immuno deficiency Virus HTI Health Training Institution IAEA International Atomic Energy Agency ITM Insecticide Treated Materials KATH Komfo Anokye Teaching Hospital LI Legislative Instrument MDAs Ministry Department and Agencies ME Monitoring and Evaluation MOH Ministry of Health MOLGRD Ministry of Local Government and Rural Development MES Ministry of Environment and Science MTHS Medium Term Health Strategy MSDS Material Safety Data Sheet NR Northern Region OD Operational Directive OPD Out Patient Department PHD Public Health Division of MOLGRD PNDCL Provisional National Defence Council Law POW Programme of Work PPME Policy, Planning, Monitoring and Evaluation RDHS Regional Director of Health Services RH Regional Hospital 8  Environmental Anaksis of the Second Phase of the MTHS-SYRPOW(2002-2006) RMS Regional Medical Stores SBDs Sub-Districts SSNIT Social Security and National Insurance Trust STDs Sexually Transmitted Diseases SWAP Sector Wide Approach TA Technical Assistance TB Tuberculosis TBAs Traditional Birth Attendants TH Teaching Hospitals TOR Terms of Reference UE Upper East UW Upper West UNEP United Nations Environment Programme UNICEF United Nations Children's Fund VRA Volta River Authority WB World Bank WHO World Health Organisation WMD Waste Management Department 9  Environmental Analysis of the Second Plase of the MTHS-5YRPOW2002-2006) EXECUTIVE SUMMARY A. BACKGROUND A proposed Second Health Sector Program Support Credit to support the Government of Ghana's health vision under the Ghana Poverty Reduction Strategy has been formulated. The proposed credit would support the Ministry of Health to implement its Medium Term Health Strategy (MTHS) and corresponding 2002-2006 Program of Work (POW). The Credit would finance a portion of combined Government and external assistance budgets for policy development and operational activities. Programme Description The programme is the second phase of phase of the Medium Term Health Strategy and Programme of Work, 2002-2006. The programme involves infrastructure development which will mainly focus on rehabilitation of existing facilities and only limited new development in the deprived, low access areas of the country. In this regard the following infrastructure development activities, which were not completed under phase I would be undertaken: * Construction of 81 new health centres. * Rehabilitation of 198 health centres * Construction of 2 new district hospitals * Upgrading of 11 health centres to district hospitals * Rehabilitation of 28 district hospitals * Construction of 40 new district health management team offices. * Rehabilitation of 5 regional hospitals * Rehabilitation of 10 regional health management team offices * Rehabilitation of 14 training institutions. These activities would be financed by the Ministry of Health under it's second phase programme of work, 2002-2006. The above programme activities constitutes the total infrastructural development programme of the MOH, which the World Bank's credit wouldfinance just part of it. An environmental and social analysis was conducted to: > Assess any potential environmental and social impacts that could emanate from investing in the expansion and improvement of basic health services delivery and facilities through the implementation of MOH's MTHS and 2002-2006 POW. > Assist MOH in defining actions to mitigate the environmental and social adverse effects of its activities. > Assist MOH in planning for the building up of its capacity on the longer term to address health related environmental issues. 10  Environmental Analysis of the Second Plhase of the MTHS-5YRPOW(2002-2006) B. METHODOLOGY (a) Methods and Techniques used in assessing and analysing the impacts In order to meet the objectives of the research primary data was collected and analysed. The instruments and tools used were mainly interviews, consultations, questionnaires, checklists and literature such as the terminal reports on the first phase of health sector support program. The questionnaires were the structured interviewed type consisting of both closed and opened questions. (b) Field Work As part of the methodology for the environmental analysis, familiarisation visits were undertaken to some selected health facilities within the scope of the MTHS and five year POW. During the field visits it was observed that: (i) Rehabilitation of health facilities in certain areas are completed whilst others are on- going. (ii) The current status and potential impacts of the health facilities with regard to the hospital management practices and body contamination from waste disposal taking into account HIV/AIDS. At most of the health facilities there are severe logistic inadequacies in terms of both human and material resources for health-care waste management. (iii) The existing environmental management responsibilities and organisation are not adequately addressed, although the awareness to do so exists as there is the unavailability of sufficient resources for Health-care waste and environmental management. The effect is the relegation of the focus on environmental management activities, inadequate resource allocation for environmental management and effective integration of environmental concerns into the entire Health-care delivery system. (iv) There are limited training and capacity building resources (v) Data on waste load generation at the various health institutions are however not adequate. There are neither sufficient facilities nor reliable scientific methods in place for health care waste load determination. C. POTENTIAL ENVIRONMENTAL AND SOCIAL IMPACTS The following are the potential environmental impacts: (a) Potential Contamination of Soil, Water, Air and Handlers of Hospital Waste There is a high potential for infection and chemical contamination of soil, particularly from liquid wastes flowing into soil. 11  Environmental Analysis of the Second Ploase of the .4THS-5 YRPOW(2002-2006) The potential of contamination from untreated sharps, placenta, other body parts and infectious wastes buried or dumped crudely. This may lead to entry of pathogens and chemicals into the food chain. (b) Water and Groundwater Contamination There is a high potential for infectious and chemical contamination of streams, rivers and lakes from sources such as: * Effluents from facilities flowing into gutters/drains and * Run-off from soil during rains following dumping of infectious and chemical wastes. The potential for groundwater contamination from buried infectious wastes, sharps and body parts is considerable. (c.) Contamination of Handlers Waste handlers are not always aware of risks or do not have adequate protective clothing and disinfectants. They are therefore exposed to a high potential for infection due needle stick injuries from sharp objects, handling of infectious materials and body parts. There is the need for selection of not only environmentally friendly but also human friendly options to protect people from hazards (infection, chemical and ergonomic) during the collection, handling, storing, transporting, treating and disposal of waste. (d) Soil Contamination and Groundwater Pollution The use of landfill as a means of waste disposal in several health establishments in Ghana is a common phenomenon. Even the teaching/specialist and regional hospitals, which are deemed to be fairly resourced use dumping grounds (the word "landfill" is most often erroneously used to refer to controlled dumping ground. This is not synonymous with the well engineered/sanitary landfill site.) through the Municipal Waste Management Assemblies to dispose off some categories of waste just like the District Health establishments. The potential impacts of the disposal in the dumping ground are the release of infectious pathogens to the air and water or the risk of access by scavengers. Further, there is the risk of subsequent disease transmission, either directly or indirectly through wounds, inhalation, or ingestion, or indirectly through the food chain or pathogenic host species. (e) Impregnation and Re-Impregnation of Bednets- From eco-toxicological considerations, deltamethrin, the active ingredient used in the impregnation has some implications for the environment if not used properly especially in high doses. Deltamethrin can induce skin sensations in exposed workers. There could be non-fatal cases of poisoning following occupational exposure when safety precautions are not followed. 12  Environmental Analysis of the Second Phase of the MTHS-SYRPOWt2002-2006) (f) Impact of Wastewater Disposal Wastewater from the Health-care establishments could contain potentially hazardous components such as microbial pathogens, hazardous chemicals, pharrnaceuticals etc. There are other related hazards such as cholera. Most of the Health-care establishments in Ghana do not have sewerage treatment plants and or municipal sewer networks. The disposal of wastewater from these health facilities finds their way into water bodies and open public drains. These practice could cause the spread of dangerous diseases and expose both humans and the natural ecology to epidemic threat and health risks. (g) Air Emissions Few air emissions could be generated from healthcare activities and would be generated from the sterilisation process (e.g. operating theatre). Other areas will be the catering and laundry departments. These emissions may be in the form of vapour and smoke. Other emissions could be generated from the incineration of waste either from open burning or from the incineration. (h) Social Assessment Among the 390 health facilities being covered by the project, 255 will be rehabilitated, 11 will be upgraded from centres to District hospitals, 81 are new constructions to be undertaken under the Ministry of Health's programme and that land acquisition may be necessary in relation to the new construction. As the exact locations are not known, the Government is taking the precautionary measure to prepare a resettlement policy framework in compliance with the World Bank Operational Policy 4.12 (Involuntary settlement), see annex 2. It is proposed that MOH carry out a social assessment with the objective to identify all those areas and sites where there will be an impact on land, people and property and access to resources due to expansion of health facilities. In cases where land acquisition will cause adverse impact on people and property or people's access to land or property, the resettlement and compensation procedures as described in the resettlement framework will be applicable. (D) PROPOSED ENVIRONMENTAL AND SOCIAL IMPACTS MITIGATION MEASURES In view of the field observations made at some of the health facilities in the country, consultations held with key persons and concerns of the relevant Departments and Agencies, the following mitigation measures are proposed: 13  Environmental Analysis of the Second Plase of the MTHS-S YRPOY200 2-2006) (a) Policy Initiatives The main trust of the policy recommendations covers an expedite completion of the national health-care waste guideline, development of health-care waste management policy and the establishment of collaboration between the HIV AIDS Project and health- care waste management activities. (i) Completion of healthl-care waste guideline The Envirormental Protection Agency (E P A) is in process of preparing guidelines as basis for the segregation, packing, handling, storage, treatment, transportation, disposal and monitoring of Health-care waste. This is being done in collaboration with individuals, organisations, Ministries such as the Ministry of Health and Ministry of Local Government and Rural Development, District and Municipal Assemblies, Sector Agencies, and other relevant institutions. An early completion and dissemination of the afore mentioned guideline provides a very good foundation and the best strategy for addressing the potential environ-mental and social impacts arising as a result of the MTHS and POW II. To facilitate an early completion and dissemination of the guidelines, the Ministry of Health, which is a key stakeholder institution and beneficiary of the output guideline document must be supported financially as well the EPA so as facilitate their cooperation towards an early completion of the document. (ii) Development of healthl-care waste management policy Upon completion of the guideline document a policy document and a technical guideline would be required to complement any legislation enactment process. It is therefore imperative that a policy document outlining the rationale for the appropriate legislation, national goals and the key steps essential to the achievement of the goals. (iii) Collaboration witht HIVAIDS Project on Waste Management There are potential environmental and social impacts due to the expansion of health facilities and basic health services particularly HIV AIDS. To mitigate these potential impacts it is recommended that the waste management programme is designed to collaborate with the National HIV AIDS project. Waste management activities could later be linked to the Lagos-Abidjan Corridor HIV AIDS Project ( when it becomes operational). (b) Health-care Waste Management These health-care waste management improvement measures include the following: * There should be regulations, guidelines or effective means of control for the storage, handling, packaging and transporting of hospital waste in Ghana. * There should be health education and training of staff with regard to the management of medical waste. 14  EnvironmentalAnalysis of the Second Pliase of the faITHS-5YRPOW(2002-2006) * All forms of liquid waste which are drained into sinks should be eventually channeled into the sewerage system. (e.g. acids and alkali should be neutralized before disposal.) * Hospital and laboratory officials should be able to indicate quantities of wastes generated. . Containers for hazardous/infectious waste should be properly labelled as a caution to handlers. * Most hospitals/clinics should be provided with adequate waste treatment facilities. (c.) Impregnation and re-impregnation of bed nets For the impregnation and re-impregnation of bed nets, two recommendations arise: (i) that non-toxic and environmentally friendlier chemicals be used; (ii) training and public awareness building of user on how to dip their beds and dispose of the used bed nets. The MOH is aware of the new and less hazardous chemicals for the impregnation of bed nets, so intended users are being better informed taking into account the increasing cost implications but being much better suited for babies. This issue is being discussed with WHO and UNICEF who are importing most of the bed nets into Ghana. Further, the National Malaria Control Programme was developed by a partnership that includes MOH, GSMF International, local and international Non Governmental Organisations, Health Partners and the commercial sector. According to the Final Draft Policy of February 27 2002 on Insecticide Treated materials (ITM) policy of the Ghana National Malaria Control Programme a policy would soon be developed by National Malaria Control Programme to spell out technical issues with regards to net/insecticides, their usage and relevant roles of stakeholders, regulatory bodies and protection of consumers. The Ministry of Health and other agencies shall train individuals to treat and retreat the net and other materials as well as the disposal of the used nets. The MOH and other agencies shall teach the proper disposal of insecticide residue following treatment. Other cardinal considerations by the drafted policy regarding the use of the ITMs are: (i) The private sector and communities are essential partners who should be involved in the planning and implementation process. (ii) Large-scale use of ITM should be a part of the vector control component within. the national Malaria Control Programme. The objectives of the drafted policy are: * To increase the use of ITMs among the population especially in children under five years and pregnant women * To ensure the safety and effective use of the ITMs that are supplied, distributed and used, and the proper disposal of insecticide. * To increase the knowledge base on ITMs. * To specify the roles for the various stakeholders * To specify the mechanism for periodic review and possible revision of this policy 15  Environmental Analtsis of the Second Phase of the AtTHS-SYRPOW(2002-2006) It is of interest to recommend to implementers of the policy of the Insecticide Treated Materials policy to use more environmentally friendly WHO type III Chemicals, which have comparative advantage in, terms of biodegradability, non toxic as well being non- persistent. Above all should be cheaper for the pocket of the average Ghanaian. (d) Monitoring Plan Effective control of Health-care waste and monitoring of facilities should be carried out regularly, in order to maintain and improve management of the waste. Measures should be adopted to ensure that problems and risks involved are identified while enhancing safety and preventing the development of future problems. E. ENVIRONMENTAL MANAGEMENT PLAN (i) IMPA CTS AND MITIGATION MEASURES The impacts summarized above in section C of the executive summary constitutes the main problem area. The proposed mitigation measures are as stipulated in section D of the executive summary. (ii) PROPOSED INSTITUTIONAL FRA4MEWORK FOR ENVIRONMENTAL MANAGEMENT (a) Institution Arrangements of a National Capacity Building Programme Ministry of Health should collaborate with institutions such as EPA, Ministry of Local Government and Rural Development, District Assemblies and Municipal Assemblies in the preparation of train the trainer activities, and competent institutions or centres for the trainers programme to be identified. This will ensure an understanding of the environmental issues. In particular, staff/workers must have an understanding of the rationale for the recommended mitigation measures and monitoring programmes that they may be implementing. (b) Training/Capacity Building Responsibilities The infection Control Officer and the Environmental Health Officer should be given the joint responsibility of training related to the segregation, collection, storage, and disposal of Health-care waste. These Officers should ensure that staff at all levels are aware of both the hospital waste management plan and policy and of their own responsibilities and obligations in this regard. (c.) Management Responsibilities Presently, the institutional responsibility rests with the Public Health Department of the District and Metropolitan Assemblies. There is the need to shift from this situation by allocating a joint responsibility to include the Ministry of Health, the Ministry of Local Government and Rural Development and the Environmental Protection Agency. The overall Strategic Management function should be the responsibility of the Ministry of 16  Environmental Anal ysis of tfle Second Phase of the MTHS-SYRPOW(2002-2006) Health, which will formulate policy guidelines and provide general direction for implementation. (d) Management Structure There is the need for a management structure to run through all levels of the Ministry Of Health. At each level, the components of the management structure should work in collaboration with all other stakeholders such as the Ministry of Local Government and Rural Development, the Ministry of Environment, the Ministry of Employment and Social Welfare, the Ghana Health Service, the Teaching Hospitals, the Environmental Protection Agency and the District and Metropolitan Assemblies with a responsibility of environmental management. The suggested structure to run through the MOH should be as follows: MOH-An Environmental Health Unit (EHU) should be responsible for policy and general guidance. The EHU should have close links with the Public Health Units and Occupational Health units of the Policy Planning Monitoring and Evaluation (PPME). The functions of the EHU could be combined with policy functions related Occupational Safety and Health. Additionally, the EHU should have a role in policy and review of environmental and health assessment. Ghana Health Service (GHS)- The GHS should have Units within the Public Health Division to monitor implementation of environmental management within the Regions, Municipalities and Districts. Regional Hospitals- Should function under Public Health Units and provide guidelines for environmental management. District Hospitals- Should have environmental health officers. Institutions (Departments and Agencies)-Should have environmental health officers. Hospitals/Health Centres/Posts- To work with committees in institutions, Departments and Agencies. The day to day administration of Health-care waste and environmental management should be the direct responsibility of a management committee to be headed by Medical Officer-in-Charge. (e) Health-Care Waste Environmental Management Committee Proper management depends on good administration and organisation, financing and active participation of trained and informed staff. There is the need to form a Waste Management Committee to develop the waste management plan. The committee shall comprise the Medical Officer-in-Charge and several members as shown in Figure 4. The functions of the committee shall be to; Develop a waste management plan for the facility which will be integrated into the daily operations of the health institution * Ensure that all on-going projects have made room for waste disposal gadgets * Consider and advise the management of health institutions on all aspects of Health- care waste disposal within the health institutions 17  Environmental Analvsis of the Second Pliase of the MJTHS-5YRPOWf2002-2006) * Inspect Health-care waste generating points to ensure that waste is kept in accordance with acceptable standards of environmental sanitation * Advise hospital management on measures to prevent endemics The committee shall be responsible to the Chief Administrator/Head of Institutions while the Public health Unit shall carry out day to day implementation of the plans. (iii) ESTIMA TED COST OF PROPOSED MITIGATION MEASURES The estimated costs of the main environmental management activities for the health establishments and total financial requirement are made up of the elements in the table below: Estimated Costs of Mitigation Measures MITIGATION MEASURES Estimated Time Cost ($) Frame POLICY ISSUES Development of Health-Care Waste Management Policy 2003 Publishing and dissemination of Health-care waste 38,000 2003 Guideline Capacity building through fora on Health-care waste 100,000 2003 Guideline Training of trainers and personnel Environmental Impact Assessment Studies for 400,000 2003-2006 Proposed Expansion and New Construction Works LAND ACQUISITION * Payment of Compensation for Land Acquisition 350,000 2003-2006 Investment Costs for Incinerators Manual loading and de-ashing, secondary combustion 2,400,000 2003-2004 chamber (temperature> I 000