1.2 program background (context & … · web viewactivities will support national polio...

COVER SHEETINITIAL ENVIRONMENTAL EXAMINATION

&REQUEST FOR CATEGORICAL EXCLUSON

PROGRAM/ ACTIVITY DATA:

Program/Activity Number: Development Objective (DO2): 663-02Program/Activity Title: Increased Utilization of Quality Health ServicesCountry/Region: Ethiopia/East AfricaDevelopment Objective: Global Health InitiativeFunctional Objective: 3.0 Investing In People

Program Area 3.1: Health Program Element 3.1.1 HIV/AIDS Program Element 3.1.2 Tuberculosis Program Element 3.1.3 Malaria Program Element 3.1.6 Maternal and Child Health Program Element 3.1.7 Family Planning and Reproductive Health Program Element 3.1.8 Water Supply and Sanitation Program Element 3.1.9 Nutrition

Funding Begin: FY 2015 Funding End: FY 2020 LOP Amount: $ 1.548 Billion

Sub Activity: ________ IEE Prepared By: Vanessa Hughes, Project Development Officer, HAPN, and Yitayew Abebe, MEO, USAID/Ethiopia Current Date: June 19, 2015

IEE Amendment (Y/N): N If "yes", Filename & date of original IEE ;

Expiration Date September 30, 2020

ENVIRONMENTAL ACTION RECOMMENDED; Categorical Exclusion X Negative Determination XPositive Determination Deferral

ADDITIONAL ELEMENTS: (Place X where applicable)

CONDITIONS X PVO/NGO: X

SUMMERY OF FINDINGS: This IEE addresses the entire portfolio of activities under the USAID/Ethiopia Increased Utilization of Quality Health Services Development Objective portfolio, applying to all activities implemented under Ethiopia’s 2011-2015 CDCS. It replaces and supersedes the Mission’s 2011-2015 Increased Utilization of Quality Health Services Development Objective IEE (Ethiopia_DO2_IIP-GHI_20011-2015) which was approved on 03/06/12 by the Bureau Environmental Officer (BEO); except that ongoing activities operating with an approved environmental mitigation and monitoring plan (EMMP) conforming to the requirements of the 2011-2015 IEE may continue operating under that EMMP.

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Recommended Threshold Determinations:Categorical Exclusions are recommended for the following classes of activities, except to the extent that the activities directly affect the environment (such as construction of facilities). Specifically, this is for activities covered by the following citations in Reg. 216, subparagraph 22 CFR 216.2(c)(2):

(i) Activities involving education, training, and technical assistance, or training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.);

(iii) Activities involving analyses, studies, academic or research workshops and meetings; (v) Activities involving document and information transfers;(viii) Programs involving nutrition, health care, or family planning services except to the extent designed to

include activities directly affecting the environment (such as construction of facilities, water supply systems, waste water treatment, etc.);

(xi) Programs of maternal or child feeding conducted under Title II of P.L. 480; and(xiv) Studies, projects or programs intended to develop the capability of recipient countries and 0rganizations to

engage in development planning, except to the extent designed to result in activities directly affecting the environment (such as construction of facilities, etc.).

Negative Determination with Conditions is recommended for any Health Care activities that have potential for adverse impact on the environment in the following categories:

Generation, storage and disposal of Special Medical Wastes , e.g. HIV testing, TB testing and laboratory-related activities

Procurement, storage, management and/or disposal of public health commodities, including pharmaceutical drugs, medical kits, supplies and/or chemical reagents;

Use of Long Lasting Insecticidal Nets (LLINs) Small-scale construction/rehabilitation of health facilities; Small-scale water supply and Sanitation; Nutrition commodities management and feeding; and Sub grants program

TABLE 1: Summary Threshold Determinations for activities under the DO 2 Health Portfolio: DO 2 Mechanisms Activities

Description of Activities ETD

Help Ethiopia Address Low TB Performance (HEAL TB)

HEAL TB’s objective is to improve TB detection and treatment in populous agrarian regions by supplementing existing Health Extension Program with alternative community-based mechanisms. HEAL TB supports a comprehensive package of tuberculosis (TB) interventions to provide quality DOTS, strengthen referral linkages to the community, and assist the Federal Republic of Ethiopia, selected regional states, and local health institutions to expand, improve and sustain TB services. Major activities are:

Strengthening and Expansion of DOTS(Improved Case Detection Rate and Treatment Success Rate) by strengthening Laboratory services and systems, ensuring proper TB diagnosis and treatment provided correctly as per the national guidelines, improving capacity of health workers to diagnose cases and place on correct TB treatment regimens, enhancing the capacity of health professionals to detect and treat TB in children and strengthening drugs Supply Management to ensure no-stock-outs of anti-TB drugs.

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Challenge TB Challenge TB will focus on strengthening TB program capacity, leadership and partnership; patient-centered care and treatment for TB, MDR-TB and TB/HIV; prevention through targeted screening, infection control and management of latent infection; comprehensive high-quality diagnostic networks; and health systems strengthening. The activity assists the GOE TB program’s efforts through comprehensive support at national and regional (SNNPR and Tigray) levels and to

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DO 2 Mechanisms Activities


urban TB activities in Addis Ababa, Dire Dawa and Harari. Special emphasis is given to key populations in congregate settings (prisons), urban poor, migrant workers and pastoralist populations within the targeted areas.

TRANSFORM/Developing regional States (DRS)

TRANSFORM/DRS will make major contributions to Ending Preventable Child and Maternal Deaths (EPCMD) results. To achieve the greatest impact in EPCMD in the developing regional states, innovative service provision models will prioritize those areas with the worst Reproductive, Maternal, Newborn, and Child Health (RMNCH) indicators. DRS will support the following four key areas:

Delivery of Priority High-Impact RMNCH Services; Capacity Building of Regional Health Bureaus in Health Systems and

Management; Quality Improvement/Quality Assurance for Health Service Delivery and

Systems Management; and Operational/Implementation Research on Innovations in Service Delivery.

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Support for International Family Planning Organizations (SIFPO)

SIFPO will increase awareness, access, and uptake of tubal ligation and no-scalpel vasectomy services as part of a comprehensive approach to FP, while exploring, identifying and seeking to remove barriers that prevent men and women from seeking voluntary permanent FP methods. SIFPO will use innovative strategies and proven practices to reach men and women with PM information and services. These include: conducting rural campaigns harnessing community mobilizers, utilizing satisfied clients, organising community events, and leveraging rural media; promoting urban campaigns with a robust urban marketing campaign, utilizing m-health, and worksite interventions; engaging men as FP clients, supportive partners, and agents of change; expanding service delivery through outreach services; and implementing e-Voucher schemes.

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Advancing Partners and Community-based Family Planning (APC)/JSI

APC’s objective is to support the Health Management and Information System (HMIS) scale-up to improve evidence-based decision making. The program strengthens data collection, management, analysis and utilization at all levels of the health services delivery system. Helping to prevent maternal and child deaths, the information generated from this system is critical to regularly monitor health services and the status of disease patterns, and to plan future health interventions. Major activities include:

Rollout of the revised HMIS and community-based family folders, part of a comprehensive community health information system;

Medical records scale-up; Promote data quality assurance, data use and strengthening ownership at

national and regional levels.

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Maternal Child Survival Program (MCSP)- Basic Emergency Obstetric and Newborn Care (BEMONC)

MCSP will scale up BEmONC services, improving performance and quality of MNH services, improving referral linkages, strengthening existing innovations such as post-partum FP (PPFP) services and where appropriate introduce new life-saving interventions. MCSP will also play a key role providing guidance and advice to the FMOH in evidence-based approaches for maternal health programming. MCSP will increase the capacity of health facilities and skilled birth attendants to provide high quality BEmONC services. MCSP will collaborate with IFHP to expand BEmONC services to 170 woredas in IFHP-supported zones within Amhara, Tigray, Oromia and SNNP Regions. MCSP support will include providing the national standard competency-based BEmONC training followed by post-training supervision to ensure that providers have retained competency and build confidence to perform all the BEmONC signal functions. MCSP will use the results from the training needs assessment conducted by IFHP to identify health facilities with a need for BEmONC training. Activities include:

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BEmONC training; Provide guidance and technical input to relevant technical working groups

and Ministry counterparts; and Support the FMOH and RHBs to ensure PPFP contraceptive options,

including Lactational Amenorrhea Method, post-partum intrauterince contraceptive device and postpartum tubal ligation are well addressed in the national FP guidelines as a long-term FP method.

MCSP- Community-Based Newborn Care (CBNC)

CBNC addresses antenatal, labor and postnatal aspects of newborn care and prioritizes community management of newborn sepsis. CBNC will support the Government of Ethiopia (GOE) to scale up high-impact newborn care interventions in communities and primary health care facilities through demand creation, universal provision of quality high impact services and strengthened support systems in 12 zones and 1 special woreda. Major activities include capacity building of woreda and health center staff to:

Provide high quality integrated supportive supervision to CBNC-trained HEWs;

Conduct clinical review meetings; Ensure data quality; and Strengthen systems for commodity security.

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MCSP WASH/NTD The overall goal of the Maternal Child Survival Program WASH activity is to support the GOE's goal of reducing under-five morbidity and mortality associated with WASH-related diseases such as diarrhea and malnutrition. The activity will:

1. Increase the provision of WASH services at public health facilities through: Providing support for targeted water supply infrastructure construction and rehabilitation; Improving sanitation facilities through construction of latrines at health centers and health posts that do not have access to adequate sanitation facilities; and providing hands-on refresher training for health care staff in improved hygiene behaviours.

2. Increase the capacity of water point managers to use and maintain WASH services through: Building the capacity of WASH committees to ensure sustainability of services; and building capacity of HEWs to understand options of improved sanitation and hygiene products.

3. Test and Disseminate models for private sector engagement in WASH through increasing the knowledge base of existing WASH products available in commercial markets in Ethiopia; Support the GOE to reduce WASH-related disease burden through increasing the availability and utilization of WASH products and services in target communities.

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Malaria Laboratory Diagnosis & Monitoring (MLDM)

MLDM aims to strengthen malaria diagnostic capacity at Ethiopian public sector laboratories via technical, strategic, managerial, and operational support in five regions of the country via the Ethiopian Public Health Institute (EPHI). Activities will include:

Review the updating and development of malaria laboratory diagnosis policy guidelines and training materials;

Conduct training of health professionals in malaria laboratory diagnosis and quality assessment/quality control (QA/QC);

Support the establishment of a QA/QC system for malaria laboratory diagnosis in health facilities, including onsite supportive supervision and

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mentoring; Conduct studies on therapeutic efficacy of anti-malarial drugs, G6PD and

serology; Facilitate the establishment of a national malaria slide bank; Train malaria laboratory professionals Regional Reference Labs as trainers.

Indoor Residual Spraying (IRS)

IRS implements best practices and environmentally compliant indoor residual insecticide spraying operations to reduce malaria transmission in Ethiopia, especially in the Oromia Region. The goal of IRS is to build the capacity of vector control specialists to conduct best practices in IRS operations, as well as carry out entomological monitoring of insecticide resistance and residual efficacy of insecticides. Activities include:

Improve IRS targeting and implementation; Environmental compliance monitoring & environmental compliance best

practices; Training, community mobilization via health extension program and improve

district, regional & national level planning, implementation and monitoring of IRS operations.

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Urban HIV/AIDS Nutrition and Food Security Project

Target beneficiaries are OVC referred by another PEPFAR partner, the Yekokeb Berhan (YB) mechanism. OVCs are screened by YB mechanism using established Child Status Index (CSI) criteria, and those found eligible for food support are referred to the Community Coordination Committee (CCC) for further screening and issuance of food vouchers. Food is distributed by cooperative associations at the community level. YB local partners undertake rigorous screening of those eligible for food support because the need surpasses the budget. Food support to OVC is a core activity for PEPFAR Ethiopia, and geographic coverage of beneficiaries is determined by the YB mechanism. Food aid for OVC is available in geographic locations where both the UHNFS and YB mechanisms operate. The UHIS capture OVC information at the town levels and enables the partner to track each individual client’s health and food security status. Major activities are:

YB sub-partners will conduct home visits to assess OVC nutritional status; provide nutritional counseling to guardians;

Provide psychosocial support to OVC; and refer them to health facilities for treatment if there is evidence of growth faltering, stunting, or malnourishment.

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Strengthening the Federal Level Response to Highly Vulnerable Ethiopian Children (Yekokeb Berhan)

The main objective of the program is to reduce vulnerability among OVC and their families by strengthening systems and structures to deliver quality services to increase resiliency through a family-centered care and support approach. The major activities for this program are:

Building the capacity of stakeholders to effectively use improved data management system and employ a national OVC supervision system;

Employing effective and efficient family centered, age –based and inclusive OVC care management system;

Enhancing the capability of communities for coordinated and improved responsiveness towards OVC care; and

Establishing effective and efficient monitoring, evaluation, reporting and learning system ensuring evidence based programming and policy making.

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Preventative Care Package (PCP)

The project goal is to mitigate the impact of HIV/AIDS and improve quality of life of PLHIV and their family members. Specific objectives are to: 1) ensure that PCP components are available, acceptable, and sustainable and 2) increase uptake of and adherence to HIV clinical services. Major activities include:

• Procurement, packaging and distribution of adult and pediatric Preventive

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Care Packages kits at PEPFAR ART health facilities for adults and children living with HIV and AIDS;

• Production and distribution of IEC materials, job aids and demonstrations available in health center waiting rooms;

• Provide training to facility care providers including case managers and NEP+ community volunteers that conduct house to house follow-up and education/counseling on the PCP kit utilization and ART drug adherence.

National Network of Positive Women Ethiopia (NNPWE)

The National Network of Positive Women Ethiopians (NNPWE) is a local organization and a specialized Network of People Living with HIV association identifying HIV-positive women as its main target. NNPWE aims to support formation and functioning of HIV positive women associations and regional networks across the country for peer support. The goal of this mechanism is to improve health outcomes among women living with HIV and prevent new infections among newborns. The project is implemented in Amhara, Oromia, SNNP, and Tigray regions and Addis Ababa administrative city. Major activities are:

Increase PMTCT and family planning service uptake among women; Improve adherence to treatment; Reduce gender-based discrimination in access to services; and Strengthen the institutional capacity of NNPWE and its member

associations.

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Hope for Children (HFC)

The Integrated Community-Based HIV/AIDS Care and Support and Prevention project implemented by Hope For Children (HFC), will provide care and support services for HIV-infected and affected people. The project goal is to improve quality of life of people affected by and infected with HIV and AIDS in 9 towns in Amhara, Oromia and SNNP regions. Specific objectives are:

Strengthened institutional capacity of 33 community-based organizations (CBOs) to manage community based life improvement initiatives;

Enhanced financial and social capital of 9000 people affected by and living with HIV and AIDS;

Improved literacy and life skills of 1600 households on positive family life and safe touch of children; and

Promotion of care and support for 6600 PLHIV.

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GEMS GEMS is conducting external field monitoring and evaluation of environmental compliance/management to indoor residual spraying (IRS) operations to ensure that PMI’s IRS activities comply with 22CFR216, WHO, FAO and Ethiopian EPA standards. This external evaluation takes place in the middle of IRS operations following pre-IRS internal assessment and review of EAs. This field monitoring includes the following activities of IRS operations:

• Management and supervision• Worker health and safety• Storage and stock control• Transportation• Technical aspects of spraying operations• Wash activities• Effluent waste disposal• Solid waste disposal.

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Malaria Care Provide comprehensive technical assistance, implementation support, and global leadership for improving country capacity to scale-up programs that provide high-quality diagnostic and treatment services for malaria and other key childhood

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illnesses and infectious diseases. Key activities include: i) assist in the establishment of malaria slide bank, ii) strengthen PCR capacity at the EPHI for validation of malaria slides, and iii) support in delivering Malaria Microscopy Accreditation Course

Strengthening Community Response to HIV

Building capacity to effectively respond to and mitigate the impacts of HIV on adults and children. Objectives and activities are yet to be determines.

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OVC follow-on Mitigate the impact of HIV/AIDS on children through improved Ethiopian systems and structures. Objectives and activities are yet to be determined.

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Private Health Sector Program (PHSP) follow-on

The Strengthening Health Outcomes though the Private Sector (SHOPS)-PHSP follow-on activity provides technical assistance to 203 private facilities to provide high impact primary health services in private clinics. PEPFAR funds will be used to provide comprehensive HIV services specially for key and priority populations, TB and Malaria funds expand and enhance DOTS and Malaria treatment; MCH/FP/RH and funds will be used to ensure better access and quality of maternal and child health and FP/RH services. The activity will continue providing TA and building the capacity of accredited private clinics to provide quality health care services. The activity will also ensure the flow of TB, malaria and FP commodities and supporting materials from Regional Health Bureaus to private facilities to improve health services.

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TB follow-on The TB follow-on mechanism will assist the GOE TB program activities at national, regional and implementation levels with focus on strengthening TB program capacity, leadership and partnership for sustainable TB services. The activity will base its interventions on the GOE’s HSTP objectives and strategies as well as the USG global TB strategy. The activity will focus on the following objectives: 1) improving access to high-quality, patient-centered TB, MDR-TB, and TB/HIV services; 2) Preventing TB transmission and disease progression; 3) Strengthening TB service delivery platforms and 4) Accelerating research and innovation.

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Local Capacity Development (LCD) follow-ons

Enhance or strengthen access to health services through local organizations. Objectives and activities to be determined.

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Malaria Laboratory Diagnosis & Monitoring (MLDM) follow-on

MLDM aims to strengthen malaria diagnostic capacity at Ethiopian public sector laboratories via technical, strategic, managerial, and operational support in five regions of the country via the Ethiopian Public Health Institute (EPHI). Activities will include:

Review the updating and development of malaria laboratory diagnosis policy guidelines and training materials;

Conduct training of health professionals in malaria laboratory diagnosis and quality assessment/quality control (QA/QC);

Support the establishment of a QA/QC system for malaria laboratory diagnosis in health facilities, including onsite supportive supervision and mentoring;

Conduct studies on therapeutic efficacy of anti-malarial drugs, G6PD and serology;

Facilitate the establishment of a national malaria slide bank; Train malaria laboratory professionals Regional Reference Labs as trainers.

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Consortium of Reproductive Health Associations (CORHA)

CORHA is a new partner through the Local Capacity Development award with USAID/Ethiopia. The goal of the Enhancing the Capacity of NGOs for Quality FP/MCH Services is to increase the capacity of CORHA and its member organizations:

1. to improve institutional capacity for planning, management, monitoring, evaluation and fund raising

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2. to enhance organizational culture for ensuring transparency and accountability

3. to increase participation and dialogue for strengthening strategic partnerships and collaboration as well as for information, experience and knowledge sharing.

Activities include: Training organizational staff and board members on identified technical,

financial/ grants management and leadership areas Trainings to improve financial management system based on sound

business principles Trainings to improve ICT structures and purchase of office equipment

TRANSFORM PHCU The long-term goal for the Ethiopian Health System is that PHCUs offering high-quality services will eventually be able to absorb the ever-increasing demand for Reproductive, Maternal, Newborn, and Child Health (RMNCH) services. This activity will focus on the four agrarian regions, which have shown the greatest improvements, but still have the greatest population density and greatest needs for EPCMD-related services and improvements. Intervention sites will be based on data points that provide input where USAID resources can have the greatest EPCMD-related impact (determined by the TRANSFORM-MELA assessment). Working through the Regional Health Bureaus, USAID support will be designed to address assistance needs of lower performing woredas and PHCUs and maintain strong performing woredas to strengthen the weaker woredas.

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TRANSFORM/Water, Sanitation and Hygiene (WASH)

TRANSFORM WASH will focus on the operationalization of innovative and strategic interventions aimed at reducing under-five mortality through increased use of WASH products and services aligned with the national One Wash National Program (OWNP). The activity will:

Increase WASH governance and management at the subnational level; Increase supply and demand for low-cost WASH products and services; and Increase the knowledge base to bring WASH interventions to scale.

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TRANSFORM / Monitoring, Evaluation, Learning and Adapting (MELA)

MELA will provide and synthesize high-quality monitoring and evaluation data for USAID/Ethiopia, with the purpose of guiding the USG and GOE in adaptive learning and management of its reproductive, maternal, newborn, and child health (RMNCH) portfolio. MELA will be implemented in parallel with the TRANSFORM activities in DRS and PHCU, and the Strengthening Ethiopia’s Urban Health Extension Program (SEUHP). Major MELA activities will include:

Comprehensive baseline, midterm, and endline evaluations; External performance evaluations; High-level monitoring; Impact evaluations of select development innovations, geospatial analyses,

and learning forums.

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Demographic Health Survey (DHS)

To support provision of up-to-date and reliable data on health and population information, USAID supports the planning and implementation of the Ethiopian Demographic and Health Surveys (EDHS). The information obtained from the DHS will provide crucial information for the planning, monitoring and evaluation of the country’s Growth and Transformation Plan (GTP), the national Health Sector Development Program, HIV/AIDS Programs, and assist in assessing the achievements of the Millennium Development Goals. The support will also strengthen the technical capacity of the Central Statistical Agency (the GOE implementing agency).

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Polio Surveillance and Response

Polio surveillance updates and implements the polio outbreak preparedness and response plan in Ethiopia. Future planning for oral polio vaccine (OPV) phase out, polio-free certification and legacy planning are key elements of the national plan

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moving forward. Activities include:

Update and support the GOE to operationalize the polio outbreak and response preparedness plan and implement recommendations for Ethiopia;

Support the Ethiopian government to strengthen systems to achieve certification-standard surveillance nationally;

Support operationalization of the Polio Eradication and Endgame Strategic Plan (2013-2018) through:a) Aiding the GOE in the planning and implementation of the OPV phase-

out; andb) Providing the GOE with technical support for legacy planning in

anticipation of polio eradication.Program Research for Strengthening Services (PROGRESS)

PROGRESS II builds on the successes of the PROGRESS project and its main objective is to enhance the family planning (FP) M&E capacity of the FMOH, not only in data collection, but also data utilization for decision making to improve programs and enable the Government of Ethiopia (GoE) to meet the goals outlined in the Health Sector Development Program IV (HSDP IV) and the upcoming Health Sector Transformation Plan (HSTP). The goal of the PROGRESS project is to support the Federal Ministry of Health in building capacity for Monitoring and Evaluation their Family Planning program.Activities include:

Establishing Centers of Excellence in M&E Geographic Expansion in the number and locations of COEs, particularly to

underserved regions Continued and Improved Technical Assistance to the FMOH to improve the

M&E of FP initiatives Support the FMOH in Monitoring and Evaluating the Expansion of

Permanent Family Planning Methods

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Health Management Information Scale-up Project (HMIS)

HMIS objective is to assist SNNP & Oromia RHBs to implement the new HMIS/M&E to produce quality data and use the HMIS information for planning & management of the health services:

To establish/strengthen a computerized HMIS data capturing, processing and reporting system at national, Regional, Zonal & Woreda levels.

To provide technical support to a) The Policy and Planning Program Directorate General, FMOH to

manage the nation-wide scaling up of the HMIS/M&E b) Federal HAPCO in scaling up of mutisectoral HIV/AIDS Information

System

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Strengthen Malaria Monitoring and Evaluation Services (SMMES)

SMMES will provide technical assistance, operational research, and monitoring and evaluation support to the Federal Ministry of Health’s malaria control program and strengthen data management capacity. The purpose is to strengthen the program and facilitate implementation of the National Strategic Plan for malaria. Activities include:

Provide monitoring and evaluation support to the national malaria control program, especially to expand malaria epidemic surveillance work;

Conduct and coordinate malaria operational research, formative evaluations and special studies including surveys such as the malaria indicator survey and impact evaluation;

Provide carefully selected specific technical assistance at national and regional levels in areas of proposal development, strategic document preparation and program management

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UNICEF/PMI UNICEF/PMI supports the Federal Ministry of Health (FMOH) through implementing CE, NDC

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the “Sustaining Malaria Reduction Interventions” program in Ethiopia. This project procures and distributes malaria commodities to districts and FMOH agencies, including the Pharmaceutical Funding & Supply Agency (PFSA). Activities include:

Procure long-lasting insecticidal treated bed nets, malaria rapid diagnostic tests (RDTs), laboratory equipment and supplies (e.g. microscopes), ACT treatment dosages, chloroquine treatment dosages, rectal and parenteral artesunate, and other drugs for pre-referral and management of severe malaria to cover national needs;

Conduct annual micro-planning exercises for commodity quantification, consumption & forecasting by district

Cover operational cost related to transportation and actual distribution of LLINs to health posts and/or communities for selected districts.

Ethiopian Society of Sociologists, Social Workers and Anthropologists (ESSWA)

The Ethiopian social service system and institutions are undeveloped resulting in shortages of qualified workers and impeding the provision of social services to vulnerable populations, including PLHIV, OVC and their families. This situation hampers transition of PEPFAR investments in social service provision. The ESSSWA’s Workforce Development objective is to improve a sustainable social service delivery system by strengthening social service workforce in four regions (Amhara, Oromia, SNNPR and Tigray) and 2 city administrations (Addis Ababa and Dire Dawa). Major activities are:

Support the training of para social workers; Support standardization and institutionalization of in-service trainings of

social workers; Build the capacity of Ministry of Labor and Social Affairs (MOLSA),

Regional Bureau labor and Social Affairs (RBOLSA)and training institutions to strengthening the social services system.

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Economic Strengthening

The main objective of this program is to improve effectiveness of economic strengthening (ES) approaches that prevent and mitigate the impact of HIV and AIDS on vulnerable households caring for children and PLHIV. The major activities are:

Build the capacity of GOE and local OVC organizations; Develop the National ES Guidelines and rollout; Standardize ES implementation and approaches; Conduct studies on the impact of ES, scale-up successful practices and

promote innovation; Increase efficiency by replacing fragmented and out-of-date practices and

facilitating provision of comprehensive and standardized TA.

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Ethiopia Health Infrastructure Program (EHIP)/Construction

The purpose of the Ethiopia Health Infrastructure Program (EHIP) is to plan, design, and construct health infrastructure in Ethiopia. The health infrastructure of EHIP includes facilities (buildings) where health services can be provided to the residents of Ethiopia, such as facilities where pregnant woman can give birth, patients can receive treatment (especially for HIV), and life-saving blood donations and transfusions can be administered. EHIP health facilities range in size, but generally disturb a land area greater than 1,000 square meters.

NDC

Population Council The general objective of this program remains: “to prevent new HIV infections, through addressing the HIV risk among the most vulnerable adolescent girls in Ethiopia, and their partners.” The domestic girls program will support the health, education, life skills, and HIV prevention needs of out-of-school adolescent girls.

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Leadership, Management and Governance (LMG) Project

The LMG project will provide training to increase the stewardship, management capacity, and skills of GOE national and regional health planners, managers, and decision-makers in the 4 larger regions (Oromia, Amhara, Tigray and SNNP), and Harari and Dire Dawa. LMG strategic interventions support the FMOH to lead and coordinate the development and utilization of standardized in-service training

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materials in line with the new FMOH directives including trainings in HIV/AIDS core competency areas to deliver quality health care services.

Development Credit Authority (DCA)

The goal of this project is to improve quality and coverage of HIV/TB, MNCH services delivered by private health facilities by improving private health sector financing. The project seeks to enhance access to loan products for private health facilities through a loan portfolio guarantee.

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Food and Nutrition Technical Assistance (FANTA)

FANTA provides TA to the Federal Ministry of Health (FMOH) to increase their capacity to plan for nutrition in general, and integrate nutrition assessments, counseling and support (NACS) in HIV services in particular. FANTA developed modules used in advocacy for increased national resource allocation for nutrition and for better coordination between ministries of Health and Agriculture, and with Nutrition stakeholders. Activities include: I

Improve capacity of FMOH and 7 Regional Health Bureaus (RHBs) to implement quality NACS;

Expand the evidence base related to food by prescription in HIV services; and

Increase advocacy support for general nutrition activities that benefit the general population including PLHIVs, as a long term strategy to food security.

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HIV/AIDS WHO The overall objective is to contribute in the HIV/AIDS prevention, treatment and care efforts through strengthening the capacity of the FMoH and RHBs to coordinate & implement the national health sector response. Activities include:

Support the country’s adoption & revision of national HIV normative guidance based on the global updates

Provide technical assistance to FMoH & RHBs in the monitoring of the implementation of the updated national guidelines;

Strengthen WHO’s technical presence at federal and regional level; Support the Global Fund CCM Secretariat; Support National level advocacy and events

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Architecture and Engineering for EHIP

Provide design and oversight services for EHIP activities - The purpose of the Ethiopia Health Infrastructure Program (EHIP) is to plan, design, and construct health infrastructure in Ethiopia. The health infrastructure of EHIP includes facilities (buildings) where health services can be provided to the residents of Ethiopia, such as facilities where pregnant woman can give birth, patients can receive treatment (especially for HIV), and life-saving blood donations and transfusions can be administered. EHIP health facilities range in size, but generally disturb a land area greater than 1,000 square meters.

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Support to Ministry of Education (MOE)

USAID is initiating a national-level direct support mechanism to fully transition mainstreaming of HIV and AIDS education into secondary, high school and university curriculums and extra-curricular activities under the direction of MOE. The goal is to support MOE capacity to guide, direct, and oversee curriculum changes and rollout along with needed improvements in teacher training and supervision. Activities are in line with GHI principles of local leadership and ownership.

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Support to Ministry of Labor and Social Affairs (MOLSA)

The Government of Ethiopia (GoE) and strengthen the HIV prevention and social services system in the country. The HIV prevention system strengthening effort will help MOLSA to be able to intensify its effort of making worksites safer and mitigate risk of contracting HIV in and around worksites. The outcomes from this grant will be achieved through close coordination and collaboration with other GOE Ministries like education, justice, health, women and children, along with other donor and USAID funded projects. Hence, MOLSA will focus on policy reform, develop the social services delivery mechanism/strategies, social services workforce development, improve donor and civil society coordination in social services sector, and system

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strengthening, ensure comprehensive, quality and coordinated social services for disadvantaged population. Hence, Leadership development will be a central theme for enhancing the GoE’s response to OVC and other HIV vulnerable population.

Support to Ministry of Women, Children and Youth Affairs (MOWCYA)

The primary goal of this program is to complete the transitioning to MOWCYA the full operations and management responsibility for the data management system on the status of highly vulnerable children. Activities include:

Improved knowledge management capacity of GoE; Data to inform policy and program strategies.

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Ethiopian Economic Association (EEA)

This award aims to enhance academia’s role in generating evidence for action in health care financing in Ethiopia by developing EEA’s capacity to produce evidence on health sector financing reform (HSFR) through assessments, studies, applied research, and needs-based training programs. The main objective is to build the capacity of the EEA and its members to be independent and sustainable partners for evaluations and research while providing important data on the success of HSFR.Major activities include:

Assess impact of user fees on public health facility service provision, and the behaviors of providers & seeking users;

Assess impact of private wings in public health facilities and feasibility of outsourcing some clinical services;

Provide trainings on health economics, health care financing, impact evaluations, and health resources tracking.

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Ethiopian Medical Associations (EMA)

The EMA has been selected for a Cooperative Agreement to build the capacity of its national and regional chapters to promote Continued Professional Development (CPD) which targets health professionals in six regions of Ethiopia. The aim is to improve the quality of health care services by increasing access to standardized CPD and evidence-based learning within the medical community. Major activities will include:

Developing EMA policy manuals, a CPD Framework, and a strategic plan Providing CPD design and management trainings to build capacity of EMA

staff Conducting CPD needs assessments in six regions Developing CPD modules and conducting CPD trainings

CE

Health Sector Financing Reform (HSFR)/Health Finance and Governance (HFG)

The goal of HFG is to increase the utilization of quality FP/RH, TB and MCH services through improved availability and sustainability of locally generated financial resources. HFG works with key stakeholders to strengthen a sustainable health financing system that accommodates alternative financing and management mechanisms. Major activities include:

Consolidation of the reform in all regions; Expanding the waiver system for the poor in 177 new health centers and 50

referral and university/teaching hospitals; and Generating evidence to inform policy changes.

CE

Strengthening Human Resources for Health (HRH)

HRH supports the Ministry of Health (MOH) in the implementation of their Human Resources for Health Strategy. This activity focuses on strengthening the HRH system as a whole, and supports pre-service education for the three priority health cadres identified by the Government of Ethiopia in the Health Sector Development Plan IV: midwives, nurse anesthetists, and replacement health extension workers.

CE, NDC

HSDP IV Support Provide support for the “Health Pooled Fund in Ethiopia” for the implementation of the Health Sector Development Program (HSDP IV). Activities include:

Strengthening the capacity of FMOH in co-ordination of activities in the health sector.

Enable health policy makers and key implementers to participate in local and international conferences, seminars, short study trips or visits that

CE

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contribute to useful gains of experiences and exposure in health policy development and implementation.

Support the monitoring and evaluation programs of HSDP IV (such as Annual Review Meetings (ARM), Joint Review Missions (JRMs), HSDP Mid-Term Reviews and Final Evaluations)

Build capacity and provide training at all levels of the health system (Federal, Regions, Woredas) in planning, M&E. and Harmonization and Alignment.

Sponsoring meetings of the MOH and the private health sector and providing TA on development of standards, guidelines and manuals on Public Private Partnerships.

Supply Chain Management System (SCMS)/Deliver/Central Contraceptive Procurement (CCP)

Deliver provides key logistics support to the Ethiopian Pharmaceuticals Fund and Supply Agency (PFSA), which is responsible for forecasting, quantification, procurement, distribution and management of MCH commodities, contraceptives, malaria and other essential drugs and health commodities in the public health system. Support includes training health care providers on logistics management, stock management, reordering and reporting procedures; and mentoring and supportive supervision to monitor stock levels of FP, MCH, lab commodities and OI medicines. Major activities include:

Implementation and capacity building to manage the paper and computer-based Integrated Pharmaceutical Logistics System (IPLS), with particular focus on MCH and FP commodities in the Logistics Management Information System (LMIS) in hospitals, health centers, health posts and woredas.

CCP’s objective is to procure contraceptives to ensure contraceptive security in USAID’s program focus areas, which cover more than half of the Ethiopia’s population.

CE, NDC

Systems for Improved Access to Pharmaceuticals and Services (SIAPS)

SIAPS provides TA to build institutional capacity at the MOH, 11 regional health bureaus, Ethiopian Pharmaceuticals Association (EPA), the Food, Medicine and Health Care Administration and Control Authority (FMHACA) and the Pharmaceuticals Fund and Supply Agency (PFSA) to expand services. SIAPS supports the institutionalization of the government pharmacy reforms at hospital & health center levels; contributes to improved malaria, MCH pharmacy services, and integration of MCH and PMTCT with HIV/AIDS programs; and supports the development & implementation of drug management tools & systems through assisting health facilities to establish DTC, Drug Information Services, selection of MNCH commodities, utilization of guidelines, rational drug use, wastage reduction, and enacting of pharmaceuticals regulation.

CE, NDC

Promoting the Quality of Medicine (PQM)

PQM responds to the challenge posed by the widespread availability of substandard and counterfeit medicines, which can cause treatment failure, adverse events, and increased mortality, and can contribute to the emergence of antimicrobial resistance. PQM works to strengthen the medicine regulatory system capacity of the Food, Medicine and Health Care Administration and Control Authority (FMHACA) to monitor and regulate the quality and safety of medicines available in Ethiopia. Activities will include:

TA to strengthen the national medicine regulatory, quality assurance and quality control systems focusing on MCH, HIV/AIDS, malaria and other essential medicines monitoring and surveillance programs;

TA activities at national and regional levels and collaboration with the Schools of Pharmacy will create a sustainable regulatory environment.

CE, NDC

Strengthening Ethiopia’s Urban

The goal of SEUHP is to improve the health status of Ethiopia’s urban population by reducing the incidence of TB, HIV, maternal, neonatal and child morbidity and

CE, NDC

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Health Program (SEUHP)

mortality by improving the quality, use, and management of community-level urban health services. SEUHP will scale up its family health, personal hygiene, environmental sanitation and MNCH focused services and system strengthening interventions in 49 urban areas. The service package comprises: referral for long and short-term family planning services, community-based immunization, HIV screening of pregnant women, ANC referrals and defaulter tracing, postpartum care, TB screening, and referrals.

CORE Group Partners Project

Core Group aids the GOE to eradicate polio, prevent importation and circulation of the wild polio virus (WPV) from neighboring countries and to plan and implement Ethiopia’s Polio End Game Strategic Plan in pastoral and hard to reach areas. Activities will support national polio eradication for case detection of Acute Flaccid Paralysis (AFP); community-based active surveillance in hard-to-reach areas; cross border coordination; immunization campaigns; and awareness-raising events. In addition, the Core Group will support the GOE to begin oral polio vaccine phase-out and the introduction of injectable polio vaccine.

CE, NDC

Social and Behavior Change Communication (SBCC)

The purpose of SBCC is to improve health-related behaviors in the community and to ensure sustainable, comprehensive, coordinated and evidence-based SBCC interventions at the national, regional and sub-regional levels. The activity’s objectives are to strengthen local capacity to implement and sustain SBCC activities; improve SBCC coordination and collaboration; and support SBCC activities/campaigns. Activities will include:

Update national SBCC policy, strategy, and training materials; Strengthen communication and collaboration between SBCC stakeholders; Develop, produce and disseminate SBCC materials; Train health professionals on SBCC; Identify, document and disseminate SBCC best practices; and Support GOE systems to conduct health promotion activities.

CE

Fistula This project, designed to support the Ethiopian Federal Ministry of Health’s Plan to Eliminate Obstetric Fistula by 2020, is currently funded under the Congressional Earmark for ObstetricFistula, through E2A for just over two 2 years, from June 2014 to September 2016.Activities include:

Identifying potential OF cases identified at community level and referring to treatment facilities.

Strengthening Hamlin Fistula Ethiopia's capacity for program management and monitoring in order to fosterenhanced contribution to fistula elimination.

Strengthening collaboration at all levels towards elimination of OF by 2020.

CE

Tsehai Loves Learning – Healthy Whiz Kids

Whiz Kids Workshop’s “Tsehay Loves Learning – Healthy Whiz Kids” activity is designed to improve healthy behaviors among children by promoting immunizations, hygiene, accident prevention and healthy diet and lifestyles through electronic media (mass media) and community resource centers. Health Whiz Kids will undertake the following activities:

develop curriculum; develop, produce and disseminate educational materials; produce and broadcast electronic media educational programs; develop special educational programs for children with disabilities; and establish community resource centers.

CE

Confederation of Ethiopian Trade Unions (CETU)

The Confederation of Ethiopian Trade Unions (CETU) implements the FP/RH project to expand engagement of employers in promoting and supporting FP/RH services.The activity is implemented in 50 workplaces/factories/plantations located in Oromia,

CE, NDC

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Amhara, and Afar regions. It focuses on improving availability and quality of sexual and reproductive health and maternal and child health services in the worksites. The capacity of local implementing organizations will be strengthened with USAID assistance, fostering a sustainable model for development. Through this implementing mechanism:

50 workplace-based project advisory committees will be established 50 workplace-baes STI/HIV programs will be established Families will be referred for MCH, FP, ANC, and labor and delivery services.

Organization for Development in Action (ODA)

The Organization for Development in Action’s (ODA) “Improving the Health Status of Children through Education and Communication” project aims to reduce the incidence of common childhood diseases through Behavior Change Communication (BCC) using community and school approaches. The activity will focus on in- and out-of-school youth in three woredas in Oromia. Implementation activities will include:

Building capacity of health extension workers and teachers in BCC through training/mentorship

Establishing school health clubs Facilitating community and school conversations Conducting home visits, and Developing, producing and disseminating information, education and

communication (IEC) materials.

CE, NDC

ROHI Weddu Pastoral Women Development Organization

The goal of this project is to improve the reproductive health of the pastoralist communities in Zone Four of the Afar Region. By increase the awareness of the target population including the community members, community leaders and in and out of school youth to better understand reproductive health issues, to improve their health seeking behavior; increase access to and utilization of quality reproductive health services in order to reduce maternal and child morbidity and mortality.

CE, NDC

JIMMA University Jimma University’s objective is to enable school community and faith-based organizations (FBOs) to significantly improve their knowledge, attitude and practices on malaria prevention and control and thereby improve the health behavior in the targeted districts in Jimma zone by the end of 2016. The activity is expected to:

Increase the proportion of households with comprehensive knowledge on malaria prevention from 75% to 90%

Increase the percentage of households visiting health facilities within 24 hours of the onset of fever from the baseline

Increase the proportion of pregnant women and under five children sleeping under LLIN from 38% to 70%

Increase the proportion of households with IRS and proper care for sprayed walls from 74% to 95% in project implementation districts.

CE, NDC

Health Development and Anti-Malaria Association (HDAMA)

HDAMA aims to conduct community-based awareness raising and behavioral change to reduce the malaria burden in the Amhara region. The strategies for this project are to train, mobilize and utilize school and faith based organizations (FBOs) for malaria prevention and control activities at community level. HDAMA aims to enable school communities and FBOs to significantly improve knowledge, attitude and practices on malaria prevention and control. The expected results are:

To increase knowledge, attitudes and practices of the target population by 30% on malaria prevention and control by 2016

To foster participation of school communities in 125 schools and 125 FBO leaders in community mobilization and information dissemination to improve utilization of malaria prevention services in targeted 5 districts

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To strengthen local capacity to conduct school and FBOs based malaria SBCC in targeted 5 districts over three year period

Health Communication Capacity Collaborative (HC3)

HC3 will build capacity to design, implement, and evaluate SBCC programs focusing on core populations in HIV hot spots across Ethiopia. The goal is to increase capacity of the GoE to provide technical leadership in SBCC; increase capacity of SBCC professionals and institutions; and increase the practice of HIV preventive behaviors among high priority core populations (CPs).Capacity building strategies will target Federal HAPCO and MOH, regional HAPCOs and Health Bureaus, as well as HIV/SBCC practitioners.

CE, NDC

MULU 1 – HIV Prevention for Most-At-Risk-Populations (MARPS)

MULU-1 is the flagship HIV/AIDS combination prevention (CP) program and contributes to the overall goal of reducing new HIV infections by half as stated in Ethiopia’s strategic plan (SPM-II). The project targets key populations and other priority populations (OPP) including PLHA not on treatment, discordant couples, male clients and boyfriends of FSWs, and women and girls engaged in transactional sex. MULU-1 is responsible for reaching 80% of FSWs with a fully-integrated prevention package of behavioral, biomedical, and structural interventions.

CE, NDC

MULU 2- Workplace HIV Prevention Program

MULU II will implement targeted HIV testing services for employees, their families and other priority populations in surrounding communities of large-scale worksites. Targeted HIV counseling and testing of migrant workers is core to PEPFAR Ethiopia’s strategic focus as this sub-population is identified as highly vulnerable in the GoE’s 2013 epidemiologic synthesis. HIV testing and counseling services are part of a combination prevention approach promoted by MULU II in selected worksite. MULU II will reduce new HIV infections through implementation of combination prevention in selected large-scale worksites. Migrant workers are core to PEPFAR Ethiopia strategic priorities. The program also reaches sex workers and persons engaged in transactional sex who are part of the employees’ sexual network in the surrounding community. The program will support up to 100 large-scale worksites to implement its behavioral, biomedical and structural interventions.

CE, NDC

In School Youth HIV Prevention

The goal of this program is to improve coordination and mainstreaming of HIV and AIDS messaging in the education system. Primary target population is high school students and first-year college students, however support to MOE to mainstream HIV/AIDS education will benefit secondary, tertiary and university students. End result will be national coverage based on demonstrations in Amhara, Tigray, Oromia, SNNPR and Addis Ababa. As the beneficiaries are general population, this is a non-core activity. Curriculum expansion will reach up to 500 high schools before full transition to MOE

CE, NDC

CE= Categorical Exclusion, NDC= Negative Determination with Condition, PD= Positive Determination, D= Deferral

Implementers Procedures:

General Implementation & Monitoring ConditionsIn addition to the specific conditions enumerated in Section 4, the negative determinations recommended in this IEE are contingent on full implementation of a set of general monitoring and implementation requirements specified in Section 4 of the IEE. These monitoring and implementation requirements are summarized as follows:

The implementing partner will employ the following process for all relevant activities:

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1. IP Briefings on Environmental Compliance Responsibilities. The health team shall provide each Implementing Partner (hereinafter IP), with a copy of this IEE; each IP shall be briefed on their environmental compliance responsibilities by their C/AOR. During this briefing, the IEE conditions applicable to the IP’s activities will be identified.

2. Development of EMMP. Each IP whose activities are subject to one or more conditions set out in section 3 of this IEE shall develop an Environmental Mitigation and Monitoring Plan (EMMP) within 90 days or with the Project workplan, whichever is sooner, and provide for C/AOR review and approval. The EMMP will document how their project will implement and verify all IEE conditions that apply to their activities. An EMMP template is attached. These EMMPs shall identify how the IP shall assure that IEE conditions that apply to activities supported under subcontracts and subgrant are implemented.

(Note: The AFR EMMP Factsheet provides EMMP guidance and sample EMMP formats: http://www.usaidgems.org/Documents/lopDocs/ENCAP_EMMP_Factsheet_22Jul2011.pdf )

3. Integration and implementation of EMMP. Each IP shall integrate their EMMP into their project work plan and budgets, implement the EMMP, and report on its implementation as an element of regular project performance reporting.IPs shall assure that sub-contractors and sub-grantees integrate implementation of IEE conditions, where applicable, into their own project work plans and budgets and report on their implementation as an element of sub-contract or grant performance reporting.

4. Integration of compliance responsibilities in prime and sub-contracts and grant agreements.a. The health team shall assure that any future contracts or agreements for implementation of

DO 2 portfolio activities, and/or significant modification to current contracts/agreements shall reference and require compliance with the conditions set out in this IEE, as required by ADS 204.3.4.a.6 and ADS 303.3.6.3.e.

b. IPs shall assure that future sub-contracts and sub-grant agreements, and/or significant modifications to existing agreements, reference and require compliance with relevant elements of these conditions.

5. Assurance of sub-grantee and sub-contractor capacity and compliance. IPs shall assure that sub-grantees and subcontractors have the capability to implement the relevant requirements of this IEE. The IP shall, as and if appropriate, provide training to subgrantees and subcontractors in their environmental compliance responsibilities and in environmentally sound design and management (ESDM) of their activities.

6. Health team monitoring responsibility. As required by ADS 204.3.4, the health team will actively monitor and evaluate whether the conditions of this IEE are being implemented effectively and whether there are new or unforeseen consequences arising during implementation that were not identified and reviewed in this IEE. If new or unforeseen consequences arise during implementation, the team will suspend the activity and initiate appropriate, further review in accordance with 22 CFR 216. USAID Monitoring shall include regular site visits.

7. New or modified activities. As part of its Work Plan, and all Annual Work Plans thereafter, IPs, in collaboration with their C/AOR, shall review all on-going and planned activities to determine if they are within the scope of this IEE. If health sector activities outside the scope of this IEE are planned, the health team shall assure that an amendment to this IEE addressing these activities is prepared and approved prior to implementation of any such activities.

Any ongoing activities found to be outside the scope of the approved Regulation 216 environmental documentation shall be modified to comply or halted until an amendment to the documentation is submitted approved.

8. Compliance with Host Country Requirements. Nothing in this IEE substitutes for or supersedes IP, sub-grantee and subcontractor responsibility for compliance with all applicable host country laws and

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regulations. The IP, sub-grantees and subcontractor must comply with host country environmental regulations unless otherwise directed in writing by USAID. However, in case of conflict between host country and USAID regulations, the latter shall govern.

Government to Government (G2G) & Government of Ethiopia (GoE) long-term plans for Economic Growth related programs. For the purposes of implementation of this IEE, it will be important for the HAPN Program to regularly assess the degree to which GoE will choose to continue to outsource programs through NGOs or will shift to delivering these services directly through government employees. With USAID Forward, it is important to know the GOE’s long term plan so that USAID can provide the right types of support and capacity building to all the GoE to deliver HAPN services and to provide for the enabling environment for private sector initiative

Resource Allocation, Training and Reporting requirements:The C/AOR working with the OAA will include Environmental Compliance Language (ECL) (as per ADS 204 Additional Help) into agreements/contracts to ensure that responsibilities for environmental compliance is spelled out for the implementing partners. The implementer's quarterly reports to USAID shall contain a section specific to Environmental Compliance showing compliance with any conditions under the Environmental Threshold Determination (ETD), status of the mitigation measures being implemented, and any major modifications/revisions to the project mitigation measures or monitoring procedures. Reports will be submitted to the C/AOR) and MEO prior to and at the completion of each relevant activity at every affected project site.

The C/AOR of each project, in consultation with the MEO or REA and corresponding implementing partner(s), will actively monitor and evaluate whether environmental consequences not foreseen by this IEE arise during implementation, and will modify or halt activities as appropriate. If additional activities are added to a project but are not described in this IEE, an amended IEE must be prepared.

When deemed necessary by the A/COR and MEO, reporting will include photographic documentation and site visit reports which fully document that all proposed mitigation procedures were followed throughout implementation of the subject work including quantification of mitigation.

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APPROVAL OF ENVIRONMENTAL ACTION RECOMMENDED:

CLEARANCE:

Mission Director ___________________________________________ Date __________________________ Dennis Weller

CONCURRENCE:

AFR Bureau Environmental Officer ____________________________ Date _________________________ Brian Hirsch

ADDITIONAL CLEARANCES:

HAPN Office Chief ________________________________________ Date _________________________Elise Jensen

D/Mission Environmental officer ________________________________ Date _________________________ Dubale Admasu

Reviewed by RLA __________________________________________ Date _________________________Ying Hsu

Regional Environmental Advisor_______________________________ Date _________________________David Kinuya

Distribution List:USAID/Ethiopia HAPN Team A/CORs and Activity ManagersUSAID/Ethiopia Office of Acquisitions and AssistanceUSAID/Ethiopia Program OfficeMEO,

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INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ ACTIVITY DATA:

Program/Activity Number: Development Objective (DO2): 663-02Country/Region: Ethiopia/AfricaProgram Activity Title: Increased Utilization of Quality Health Services

1.0 Background and Program Description1.1 PURPOSE AND SCOPE OF IEEThis IEE addresses the entire portfolio of activities under the USAID/Ethiopia Increased Utilization of Quality Health Services Development Objective portfolio, applying to all activities implemented under Ethiopia’s 2011-2015 CDCS. It replaces and supersedes the Mission’s 2011-2015 Increased Utilization of Quality Health Services Development Objective IEE (Ethiopia_DO2_IIP-GHI_20011-2015) which was approved on 03/06/12 by the Bureau Environmental Officer (BEO); except that ongoing activities operating with an approved environmental mitigation and monitoring plan (EMMP) conforming to the requirements of the 2011-2015 IEE may continue operating under that EMMP.

For purposes of analysis, this IEE synthesizes current and anticipated HAPN activities into a set of twelve intervention categories. As with all IEEs, and in accordance with 22 CFR 216, it reviews the reasonably foreseeable effects of each activity on the environment. On this basis, this IEE recommends Threshold Decisions, and in some cases, conditions for these activities.

In addition, this IEE sets out activity-level implementation procedures intended to assure that conditions in this IEE are translated into project-specific mitigation measures, and to assure systematic compliance with this IEE during project and activity implementation. These procedures are themselves a general condition of approval for the IEE, and their implementation is therefore mandatory.

1.2 PROGRAM BACKGROUND (CONTEXT & JUSTIFICATIONAs described in the Country Development Cooperation Strategy (CDCS), the USAID/Ethiopia HAPN Development Objective (DO) is Increased Utilization o f Quality Health Services. The DO and Intermediate Results (IRs) aim to improve maternal, neonatal and child health, family planning/reproductive health, malaria, HIV/AIDS, tuberculosis, water and sanitation, other neglected diseases, and nutrition. The achievement of this objective is dependent on the combined success of three highly interdependent IRs:

1. Improved Provision of Quality Health and Social Services;2. Improved Health Systems Management and Integration at the National and Community Levels; and 3. Increased Appropriate Health Behaviors

USAID/Ethiopia, is adjusting the health strategy to more strongly address the HIV/AIDS epidemic, and is greatly increasing its support to key HIV/AIDS and STI prevention and response, emphasizing their integration into Primary Health Care services (PHC) (e.g., family planning, child health, reproductive health), and scaling up the national and provincial capacities to respond. Integration of key HIV/AIDS prevention activities into the primary health care system will involve Voluntary Testing and Counseling (VCT), Prevention of Mother to Child Transmission (PMTCT), Sexually Transmitted Infections (STIs) and condom social marketing. It has also increased its support to health infrastructure expansion, water supply and sanitation, etc.

1.3 USAID/ETHIOPIA HEALTH PROGRAMThe DO 2’s three IRs include key principles of the Global Health Initiative (GHI), specifically a more integrated and coordinated approach between service delivery and individual behavior change, along with an emphasis on

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systems strengthening to ensure sustainability. Activities which will be implemented under each IR are described in the corresponding Project Appraisal Documents (PAD), and detailed below:

IR 2.1 Improved Provision of Quality Health and Social Services

Sub IR 2.1.1: Increased Availability and Access to Health and Social Services

IR 2.1.1 will focus on increased availability and access to health and social services. Health service utilization has remained around 0.35 visits per person per year between 2005 and 2014. Underlying this low utilization are critical health service delivery, systems, and behavior change issues. USAID/Ethiopia has taken a holistic approach targeting cross-cutting interventions in each area of influence in order to improve utilization. This PAD will focus on the integration of proven high impact intervention services for MNCH, FP/RH, TB, Malaria, HIV/AIDS, nutrition, and NTDs, through increased availability and access at the PHCU level. USAID has and will continue to work with the GOE, as well as other donors and stakeholders, to identify coverage and service provision gaps. This project will support the HSDP IV and specifically the health extension program (HEP) to ensure there are adequately skilled health and social service providers at health facilities. Capacity building and training for competency development, improved diagnostics, and rational drug use at the PHCU level will improve service delivery. Activities in this PAD support HEWs, who are intended to bridge the gap between patients and providers by bringing information and services into communities. This increases access and two-way linkages between the community and health facilities affecting care seeking behavior and healthy practices. Strengthened referral systems will enhance the continuum of care between the community, health post, health center and hospitals. The appropriate supply of commodities and equipment will increase efficiency and effectiveness of service providers in delivering comprehensive services. Limited investments in building infrastructure and construction of water systems at the facility level will improve access to services. Private clinics and laboratories will receive technical and material support. In addition to the above activities for all health areas, the project has specific foci for each health area as follows:

MNCH - The elements most critical for achieving MNCH results in the project include clean and safe delivery, increased antenatal care, skilled birth attendance (including Emergency Obstetric and Neonatal Care), essential newborn care and treatment, immunizations, treatment of acute malnutrition through the community-based management of acute malnutrition (CMAM), and improved water and sanitation. Other activities will focus on identification, management, and referrals of fistula cases, as well as reduction of lost-to-follow-up in PMTCT, antenatal care (ANC), and immunization services. Outreach immunization campaigns and services will ensure children are fully immunized. Additional support for the scale-up of ICCM for fevers (due to malaria, pneumonia and diarrhea) should relieve the burden on secondary and tertiary health facilities as well as strengthen referral linkages. Furthermore, emphasis will be given to the expansion of women centered services into service delivery at health facilities, and assisting with rehabilitating and equipping MNCH facilities.

FP/RH – Family planning methods and provision of commodities will be expanded through the project. Key elements of family planning activities include technical and material support for outreach and counseling services through the HEP, mobile units and private clinics. Mobile units, which target remote and underserved populations, directly mitigate issues of access, while strengthening medical staff capacity through practical training opportunities. Effective models of adolescent reproductive health care will be expanded. Social franchising of private health facilities in Tigray and Oromia regions align with other activities to provide voluntary FP counseling and services. Male involvement in family planning activities will be emphasized as appropriate.

Water and sanitation – Major activities will include the development and rehabilitation of health facility water supplies and latrines, water quality testing, training HEWs and communities about water and sanitation as well as integrating water and sanitation with NTD initiatives. Consideration will be given to men and women’s societal roles in the development and rehabilitation of water supply and sanitation activities.

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HIV/AIDS - The project is designed to support efforts of the GOE in meeting the Strategic Plan II for Intensifying Multisectoral HIV and AIDS Response in Ethiopia (SPM II), which focuses on intensifying HIV prevention in Ethiopia. The strategies of this project are aligned with the epidemiological profile of the epidemic, which will primarily be targeted towards urban and peri-urban areas and “hot spots” located in the Amhara, Oromia, SNNP, Addis Ababa, Dire Dawa, Tigray, Afar and Gambella regions. New development zones including large scale farming areas, dry port and transportation corridors, and mining and industry zones will also be targeted. USAID will strategically focus on MARPs and workplaces where the epidemic is most prevalent, while transitioning general population prevention activities to the GOE. Furthermore, emphasis will be given to gender inequality and gender-based violence (GBV) as drivers of HIV/AIDS.

Components of USAIDs HIV/AIDS project are transitioning to GOE and local civil society entities to ensure sustainability. Some worksite activities and social welfare workforce development efforts will be transferred to GOE and local organizations. Building capacity through technical assistance and coordination of services will be done in partnership with GOE, including MOLSA, and MOWCYA.

HIV/AIDS Community Service Delivery – The USAID approach will be to improve health outcomes by increasing the role of key affected populations, communities and community-based organizations in the design, delivery, monitoring and evaluation of services and activities related to care, support and treatment of people affected and infected by HIV. Activities will improve community networks; linkages and partnership; access to high impact interventions; the HIV continuum of care; and M & E and evidence generation.

OVC - OVC programming supports functional social service systems and structures for effective, quality services to OVC and their families. Based on Ethiopian OVC service delivery standards, each child will receive the essential services and support that he/she needs, as determined by a needs assessment within the context of family and household. This comprehensive, quality service delivery within a continuum of care will include education services; food and nutrition services; health - preventative and curative services; care and protection; psycho-social support (PSS); shelter services; and economic strengthening and vocational opportunities. The project will strengthen referral systems; identify and address barriers that may prevent children and families from accessing key services; build capacity for service delivery; and support social service workforce development.

TB – USAID/Ethiopia’s TB control strategy bases itself on the HSDP IV, the global Stop TB strategy, and the USG global TB strategy. The strategy focuses on four major technical areas:

(i) DOTS expansion and enhancement; (ii) Strengthen laboratory services and systems;(iii) Address the challenges of MDR-TB; and (iv) Enhance TB/HIV collaborative activities.

Other key areas of focus are strengthening TB program leadership and management, proper TB diagnosis and treatment regimens, Public-Private Partnership, community awareness and TB care, strengthening drug supply management, and operations research. In alignment with the above strategies, this project will strengthen GOE TB program technical and management capacity at the national level to guide and coordinate the overall TB control effort in the country.

Malaria –Malaria activities will focus on technical, strategic, managerial and operational support to malaria control. Activities will contribute to the reduction in the number of malaria cases and deaths by improving malaria diagnostic and treatment capacity at laboratories, communities and health facilities. Additional activities include LLINs procurement, distribution and ensuring utilization, and implementing environmentally compliant Indoor Residual Spraying (IRS). Other activities will focus on monitoring and evaluation as well as health worker trainings to deliver quality health services.

Neglected Tropical Diseases (NTD) – NTD activities focus on mapping, surveillance and diagnostic systems for targeted interventions among at-risk populations. Mass drug administration (MDA), capacity building activities, as well as monitoring and evaluation systems receive support to improve control and increase likelihood of elimination.

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Sub IR 2.1.2: Improved Implementation of Quality Service Standards

Management and Capacity Building - Capacity building is a major component of this project because there is a lack of technical capacity within Ethiopia’s large and rapidly decentralizing public sector. Capacity strengthening activities will be tailored to support GOE, and local organizations within their respective roles. This project will also provide technical assistance to strengthen supportive supervision at all levels, as well as improve resource allocation and management systems. In-service training, post training follow-up, coaching and mentoring activities will contribute to increase service provider capacity. Performance reviews will provide an analysis of adequate care, improving patient-centered delivery. Client-friendly services that are responsive to existing beliefs, attitudes, practices, relations, roles, and social norms among community members will compliment improvements in quality.

Coordination – Coordination and collaboration activities enhance partnerships with GOE, other donors, NGOs and local organizations, improving the quality of service delivery. Fostering and promoting sharing of best practices and lessons learned will increase efficiency and reinforce effective approaches by service providers and managers. Patient tracking, improved referral systems and coordination between health facilities will increase timely delivery of services. Building management capacity and collaboration will improve distribution and coordination of commodities and equipment from RHBs to local communities, laboratories, and private facilities, as well as medical waste disposal plans.

Standards of Care - Activities will identify high-impact evidence-based interventions to improve service delivery implementation, management, and monitoring and evaluation through project based operational research. Working in collaboration with GOE, partners, and other donors, service delivery standards and guidelines established by the HSDP IV for functioning health facilities will be augmented. Data will be used to support policy, planning, and resource allocation, in addition to measuring results and the effect of improvements on health outcomes. QA/QI analysis will influence decision making and changes to project implementation as well as new project designs. Private clinics will receive support and guidance to provide quality services that meet GOE regulatory standards. Additional activities will assist private facilities accreditation to international standards.

IR 2.2 Improved Health Systems Management and Integration at the National and Community LevelsThe purpose of IR 2.2 is to improve health systems management and integration at the national and community levels. Activities under this IR are presented below:

Sub IR 2.2.1- Strengthened Human Resources for HealthUSAID will focus on improving the supply and quality of midwives, emergency surgical officers, nurse anesthetists and replacement HEWs using a systems approach. In 2014, Ethiopia had 5203 trained midwives; the GOE target was 7,200 by 2015. USAID support will strengthen the appropriate educational institutions, curricula and faculty, so that graduates are fully competent to provide maternal and newborn care at the PHCUs and primary hospitals.

USAID will continue its support for meeting on-going, in-service training needs of health care providers in both rural and urban areas, as well as health system leaders and managers. This will involve support for the HEP and PHCUs in both rural and urban settings and the development of systems for on-going assessment of training needs, and preparation and delivery of effective training activities. In addition, pre-service and in-service training will be offered to health and agriculture workers on food security and nutrition, to strengthen the linkages necessary to ensure a comprehensive response to malnutrition.

Sub IR 2.2.2 - Expanded Health Financing OptionsMajor elements of current USAID assistance include 1) developing the legal framework for financing reforms, 2) rolling out facility revenue retention and effective utilization of resources by the facilities, 3) developing and supporting facility governance boards (FGB); 4) developing and piloting community-based insurance, 5) implementation of fee waivers and exempted services, 6) development of private hospital wings and outsourcing nonclinical services. USAID’s health sector finance reform efforts are also focused on conducting the National Health Accounts (NHA), which provide valuable finance data for decision-making.

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Sub IR 2.2.3 - Strengthened Strategic Information for Evidence-Based Decision-MakingUSAID will continue to strengthen evidence-based decision making to address the critical health problems at all levels of the health system in support of HSDP IV. More specifically, based on the needs expressed by the MOH and findings from the assessment of IFHP in 2010, as well as the sustainability analysis recently completed for IFHP’s management interventions, this Project will support the following:

1) Refinement and Extension of the HMIS - USAID will continue its involvement in the HMIS NAC to assure that policies and the refinement of the HMIS now being rolled out are relevant and appropriate to the health systems and service delivery needs. Currently, HMIS is facility focused and heath information management for community level activities is still evolving. USAID will continue to collaborate with GOE to establish a standard framework for capturing facility level health interventions as well as for urban and rural community level work through HEWs.

2) Use of Data for Decision Making - USAID will also continue its support to Regional, Zonal, woreda, and PHCU levels to improve the quality, timeliness and completeness of routine service delivery information. Further, USAID will strengthen the capacity at all levels to use the data for planning, monitoring and evaluating health interventions and the performance of the PHCUs. The HSMI project will emphasize the use of data for decision making, planning, and problem solving at peripheral levels of the health system, with particular emphasis on the woredas and PHCUs.

3) Support to Surveys, Assessments, Studies and Program Learning - USAID will provide technical and financial support to the population-based Demographic and Health Surveys (DHS), conducted every five years, and other evaluations, research, surveillance and surveys as deemed necessary to provide the MOH with an evidence base to make sound program decisions.

Sub IR 2.2.4 - Increased Health Commodities and Essential Drug Security.Through the HSMI Project, USAID will continue its support to the GOE in the implementation of its PLMP, so as to assure an efficient, government-owned national supply chain system for health commodities with uninterrupted supply of medicines that is safe, effective, and of assured quality. USAID will concentrate on improving management and supply chain practices, optimizing distribution and warehouse networks, and strengthening and bringing in the private sector. Additionally, USAID will concentrate on strengthening the FMHACA, Ethiopia’s regulatory authority. This project will support the following:

1) Logistics Management Information System - USAID is supporting the PFSA in the roll-out of the national Integrated Logistics Management System (IPLS) for all commodities distributed via PFSA. This is a computer and paper-based inventory system, collecting consumption and stock data on all program and commercial commodities traveling through the PFSA network. The data is used to make decisions on resupply, forecasting and procurement of program commodities, as well as to manage inventory at the central and regional levels. All regional PFSA hubs are already automated with the system, and the paper-based collection tool is utilized in more than 1,200 facilities. Comprehensive training and rigorous on the job supportive supervision help institutionalize this change. USAID will support further integration of commodities for TB, malaria, laboratories, vaccines, and other essential medicines into one joint network. In addition, facilities are purchasing drugs with retained revenues. USAID will work closely with FMHACA to address institutional and organizational inefficiencies within the Authority.

Sub IR 2.2.5 - Health Service DeliveryUSAID supports implementation of HSDP IV priorities regarding the HEP with a focus on high impact interventions that support maternal and newborn health, child health, family planning, integration of HIV/AIDS services with FP/RH and MNCH services, PMTCT, and prevention and control of communicable diseases such as malaria, through a continuum of quality care at the primary health level. USAID support includes providing technical assistance to expand and improve the quality of health services, as per the standards set for functioning health facilities; limited investments in building infrastructure and construction of water systems at the facility level, and strengthening effective linkages between the community and the facility to improve care seeking behavior and healthy practices.

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Facility service standards include speed and timeliness of service delivery, coordination of services at the service delivery point through the integration of vertical programs, uninterrupted supply of commodities and equipment, and competent staff. In order to improve health service delivery, USAID and the GOE aim to create a health system that satisfies the community’s health care needs through the fulfillment of the required inputs, delivering safe and optimum quality health services in an integrated and user-friendly manner. The majority of the infrastructure activities will be covered by the on-going Ethiopia Health Infrastructure Program (EHIP), which began in 2011 and is scheduled to end in 2017. In the future USAID will focus on the PHCU to strengthen its health delivery systems. Key areas that USAID will support under this subcomponent are described below.

1) Increase Availability of Quality Health Services - USAID will continue to provide technical assistance to support and strengthen the capacity of the GOE to effectively deliver high impact interventions at the primary health care level. Investments will support improvements in the quality of services, including timely delivery of services, optimal organization and coordination of services including strengthening referral systems and improving the continuum of care so that services meet standards and norms and patients receive quality appropriate care.

2) Improve household and community practices - USAID will continue its support to the GOE in its effort to promote health through the HEWs. Currently the GOE has embarked on a newer initiative for its interventions on health communication and promotion. This initiative, called the health development army (HDA), employs a 1-5 networking approach in which one model family of graduate volunteers to work with five other community members in order to facilitate their graduation as model families. The health extension workers closely work with the HDAs to bring about behavioral change. USAIDS’s support will mainly focus on enhancing the capacity of the HEP and the PHCU to ensure evidence-based IEC/BCC approaches are employed to increase community and household knowledge awareness of healthy behaviors and practices, as well as the use of health services at the facility level. These efforts will address the determinants of relevant behaviors including harmful traditional practices and cultural norms in order to improve health seeking behaviors/practices, and establish antenatal care, institutional delivery and family planning as cultural norms. The IFHP II and a new BCC project will support these activities.

3) Improve Health Infrastructure - USAID will invest limited funds towards the improvement of health infrastructure that directly impacts on decreasing maternal, newborn and child mortality such as labor and delivery units. USAID will construct and renovate health facilities in order to health services. Water systems for select health facilities will be supported. In addition, logistics partners are supporting the construction of warehouse hubs for distribution of essential medicines and commodities throughout the country. USAID will support the GOE effort to avail power and water supply in selected health facilities. The focus will be on the PHCU to provide water and power to health posts and health centers.

Sub IR 2.2.6 - Strengthened Leadership in Policy Development, Management and Governance at All Levels of the Health SystemThe HSMI Project will continue its support for capacity building and institutionalization of management systems and tools. It will support effective and efficient application and execution of national systems, such as the LMIS and the HMIS, at the regional levels and below. Improved management with a focus on both performance and good governance plays a critical role in assuring that all health systems components improve and sustain the coverage and quality of health services, as well as health promotion and demand creation at the facility and community levels. USAID will continue to promote the sharing of best practices from one region to another.

The LMG Ethiopia project will closely collaborate with the FMOH, RHBs, Zonal/District Health Offices, training intuitions, professional health associations, and civil society organizations to: 1) standardize and accredit needs-based, in-service training for the health sector through an integrated system ensuring rigorous harmonization, standardization and accreditation processes; 2) develop the leadership, management and governance capacity of select FMOH Directorates and agencies, as well as select RHBs Bureaus/Zonal/District Health Offices, through leadership, management and governance training so they can absorb new responsibilities for managing and delivering standardized in-service training to improve health services; and 3) strengthen the institutional capacity of Ethiopian training organizations and professional health associations, to help them achieve institutional, programmatic and financial sustainability.

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At the national level USAID will support the development of policies, regulations, and tools that improve management systems (e.g., planning, buHealtheting, M&E) and will help assure increased coverage and the effective delivery of quality health services down to the community level.

a) Management and Health Systems Implementation USAID will strengthen the capacity of health system leaders and managers to effectively implement management tools and practices from the regional level down to the community, with particular focus on the woreda and PHCU levels.

IR 2.3 Increased Appropriate Health Behaviors

Sub IR 2.3.1 Improved knowledge and health practices at the household and community level

IR 2.3.1 will focus on efforts to increase individual disease prevention behavior and utilization of MNCH, FP, HIV/AIDS, nutrition, TB and malaria services to achieve improved health. Determinates of behavior change extend beyond the individual and basic dissemination of health information. Achieving sustained behavior change requires an approach that addresses the entire spectrum of influence and support around individual Ethiopians, including families, school and employment networks, community/religious leaders, as well as other social and community networks/organizations. The Healthy Behavior (HB) Project will support and strengthen government-initiated community-based interpersonal communication (IPC) interventions through the HEP as a means to engage communities throughout Ethiopia in genuine and measurable partnerships in all stages of communications design, delivery, and oversight. Other SBCC activities will include peer education, trainings, small group events, and health activities at schools and worksites. In order to maximize influence, audience segmentation based on age, sex, religion, marital status or profession will be considered. To ensure that SBCC programs are sustainable and relevant to social norms, contexts, and risk factors in different regions, the HB Project will garner grassroots participation. Gender, among other factors, is a powerful influence on all aspects of behavior change and can ultimately bring unexpected problems or reinforce existing beliefs, attitudes, practices, relations, roles, and social norms around inequality. Gender equality is not solely about women and girls, but also about engaging men and boys and mobilizing communities to take action. Priorities under IR 2.3.1 seek to build community level networks and support systems that can facilitate a more positive normative environment for disease prevention and health care use and provide community-based delivery of effective and sustained health education. Consequently, SBCC activities will develop interventions that are tailored to each community’s world view and how they construct their own health beliefs and decision-making.

USG-funded SBCC activities will build on successful prior experience in increasing Ethiopian’s use of targeted services and improving self-reported, healthier behaviors. SBCC efforts will become more research intensive and increase the emphasis on the delivery of better integrated and ‘actionable’ health messages related to MNCH, FP, HIV, nutrition, TB and malaria. Specific activities will be targeted in order to achieve (i) an increase in demand for, and the correct and consistent use of health services; (ii) improving health behaviors and product use; (iii) improving client-provider communication; and (iv) improving social norms.

Sub IR 2.3.2 Improved system for SBCC activities and messaging at all levelsThe purpose of IR 2.3.2 is to define the parameters and results for standardized and harmonized SBCC interventions to increase disease prevention behaviors and improve health care-seeking in the community. This will be achieved through USAID support to the national, regional and local level health sectors, utilizing the GOE’s HEP as the primary vehicle for prevention of disease, health promotion, social and behavioral change communication and basic curative care at community level. USAID will support improved systems for SBCC, including the coordination of communications campaigns, technical assistance, and capacity-building for SBCC. The major activity under this sub-IR will be USAID/Ethiopia’s flagship program on Integrated Social and Behavioral Change Communication in Health (SBCC-HEALTH). This mechanism will strengthen SBCC coordination and collaboration between national, regional and local level health communication systems. The objectives under this sub IR are to:

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Strengthen systems for SBCC: USAID will work closely with the GOE to establish a sustainable health system platform that will enhance the effectiveness of SBCC. This project will support the development of a new or revised National Health Communications Strategy, which will be aligned with the HSDP IV, encouraging country ownership and investment. The new strategy will need a strong organizational structure that is integrated within the FMOH and other line ministries. This includes coordination with GOE and local organizations at national, regional, woreda and kebele levels and a structure for streaming health campaigns throughout the country and into mass media, community mobilization, and IPC channels. Support and coordination with the HEP at community levels in updating the family health card messages used by the HEW and HDAs will improve message dissemination as well as SBCC monitoring and evaluation. Working in close collaboration with FMOH, the project will develop and implement a quality assurance system for health SBCC interventions as well as streamlined approaches and tools to measure and improve quality.

Capacity building: The HB Project will build capacity of national and regional health and education bureaus, woreda and kebele level providers, as well as local institutions, including NGOs, CBOs, and FBOs to design, coordinate, manage, implement, and evaluate SBCC programs and interventions. Capacity building would include SBCC pre-service and in-service trainings, distance learning, shared best practices, mentoring and coaching for GOE health and education providers at all levels as well as local organizations. Capacity building is a major component of this Project because there is a lack of technical capacity within Ethiopia’s large and rapidly decentralizing public sector. Local organizations who have been selected to implement SBCC activities will receive technical assistance in order to ensure they have the skills and motivation to deliver effective social and behavior change research and programs in the face of changing public health needs. Capacity strengthening activities will be tailored to support GOE, and local organizations within to their respective roles.

Execute evidence-based SBCC initiatives: Implementing a systematic, evidence-based health communications strategy is one of several “high-impact practices” (HIP) identified by a technical advisory group of international experts.1 When scaled up and institutionalized, HIPS have proven to maximize investments. USAID will support scale-up and sustainability of evidence-based best practices in all stages of SBCC development that are tailored to the Ethiopian environment. This will include the use of a variety of behaviorally-sound communication strategies such as mass media, social mobilization, community-level activities, and IPC to influence individual and collective behaviors that affect health. The Project will target resources and support health communications initiatives that are aligned to the drivers, context, and evolution of each particular health issue based on epidemiology and other relevant quantitative and qualitative data. This includes a focus on specific data from target audiences, geographic areas, and behavioral drivers most salient to the issue. Communities as well as interventions will be analyzed from a gender perspective. This analysis will examine the ways in which gender influences health needs and concerns, the reception of health messages, and access to and control over health communication interventions.

Strengthen coordination and integration: To address fragmented and inconsistent messaging, the HB Project will support comprehensive coordination, integration and harmonization of messaging, utilizing, to the extent possible, existing GOE coordination structures. Such coordination would help harmonize approaches and reduce duplication among partners and other donors, facilitate scaling-up of evidence-based approaches, improve resource sharing, technical updates, and sharing of qualitative and quantitative research. USAID Partners will support strengthening of the Health Communications TWG as well as coordination and planning workshops for GOE and key partners/donors/stakeholders. Support for a media forum for national messaging, events, and publications will be provided. Optimal roles and responsibilities of public sector bodies, local and international NGOs and the private sector will be assessed and determined. Initially this will include a mapping of stakeholders/donors/partners to identify overlaps and gaps in the area of SBCC intervention. Existing strategies, messages, materials, and tools will be revised and standardized. Training materials will be reviewed, adapted and/or developed in order to finalize standardized SBCC approaches and activities that will be implemented throughout the country. All of these coordination and collaboration activities would be in

1 http://www.fphighimpactpractices.org/about

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line with the GOE HSDP IV and would enhance partnerships with other donors as well as key GOE entities including the FMOH, RHBs, REB, HCU, HAPCO, and the HEP.

Strengthened strategic information for evidence-based decision making: The HB Project will support the development of a cohesive SBCC monitoring and evaluation system that will inform program development and implementation. This will include the integration of social research into program planning and implementation, and the use of information systems to monitor the effect of interventions and changing dynamics of disease profiles and epidemiology within the country. In addition, USAID will support research to develop new ways of influencing key social and cultural behaviors that limit access to and utilization of MNCH, FP, HIV, nutrition, TB and malaria services to bring about positive behavior change. The research will focus on how to shift social norms, address gender roles and cultural practices as well as set up and test different models for engaging the media, civil society, and influential community members as full partners in the process of behavior and social change.

2.1 COUNTRY AND ENVIRONMENTAL INFORMATION (BASELINE INFORMATION)

2.1.1 OVERVIEW OF HEALTH SECTOR IN ETHIOPIAAs Africa’s second most-populous country, Ethiopia has a large, predominantly rural (82%), and impoverished population. While there have been significant improvements, the population as a whole still has poor access to clean water and sanitation, marginal access to and/or utilization of quality health services, low literacy levels, and persistent food insecurity. These factors contribute to a high incidence of communicable diseases including TB, HIV/AIDS, malaria, NTDs, and respiratory infections, as well as nutritional deficiencies and some of the world’s highest rates of maternal, neonatal, and child mortality. Although the GOE has made tremendous progress in developing state-of-the-art health policies and expanding both its physical infrastructure, and availability of trained service providers, utilization of potentially high-impact services such as antenatal care, family planning, facility-based labor and delivery services, and PMTCT services, remain low.

Table 1. Key Health and Population Indicators in Ethiopia

Indicator Source

Population 94,101 WHO (2013)Proportion of population living in rural areas

81% WHO (2013)

Per capita income $1340 USD WHO (2013)

Life expectancy 64 years WHO (2013)Fertility rate 4.1 Mini Ethiopian Demographic Health Survey

(EDHS) (2014)Contraceptive prevalence rate 42% Mini-EDHS (2014)Modern Method CPR 40% Mini-EDHS (2014)Maternal mortality rate 420/100,000 births WHO (2013)Proportion of deliveries assisted by skilled birth attendant

15% Mini-EDHS (2014)

Under-five mortality rate 64/1,000 live births WHO (2013)Neonatal deaths 42% of under-five

mortalityDHS (2011)

Orphans and Vulnerable Children 4.5 million (900,000 from HIV/AIDS)

UNICEF (2012)

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Fully immunized children ages 12-23 months

24% DHS (2011)

TB incidence (all forms) 210/100,000 WHO (2014)Children under 5 years old sleeping under ITNs

38% HMIS

HIV prevalence 1.3% (7.7% urban, 0.6% rural)

UNAIDS (2012)

HIV positive children receiving ART 9.5% 2014 Country Progress Report

Health cadres : Physicians per 10,000 patientsNurses/midwives per 10,000 patients

.32.4

WHO (2014)

Health posts Health centers Hospitals (public)

16,2513,315 150

Annual Performance Report (2013/14)

Under-Five Mortality and Nutrition: Ethiopia has made great progress since 2005 as evidenced by reaching the Millennium Development Goal (MDG) 4; under-five mortality has decreased by 44% from 123 to 68 deaths per 1,000 births (DHS 2011). However, neonatal death rates have seen no significant change and now account for 42% of the under-five mortality. Ethiopia is one of the five countries contributing to half of the World’s under-five mortality. Malnutrition rates, according to the Ethiopian Mini Demographic Health Survey (EMDHS) 2014, continue to be very high with 40% of children under five stunted (low height for age which indicates chronic malnutrition) and 9% wasted (low weight for height which indicates acute food shortage and/or disease). Food insecurity, low utilization of health services, as well as inappropriate feeding practices impact these high malnutrition rates.

Immunizations: According to the 2011 Demographic Health Survey (DHS), only 24% of children ages 12-23 months were fully vaccinated at the time of the survey, which is a 19% increase from the 2005 DHS, but far below the goal of 66% coverage as set in the GOE Health Sector Development Programme IV (HSDP IV). Though most health facilities are accessible to the community, only 24% of health facilities are actually providing immunization services on a daily basis (NICS 2012).

Maternal Mortality: Ethiopia has one of the highest rates of maternal mortality in the world at 420 per 100,000 live births (World Bank 2013). Access to and utilization of quality MNCH services, including skilled birth attendants, is limited, especially in rural areas, and an estimated 20,000 women die from childbirth-related causes every year (DHS 2011). According to the EMDHS 2014, only 15% of births were delivered by skilled health personnel, up from 10% in 2011, but far below the regional average of 48%. Additionally, it is estimated that over 37,000 women currently suffer from obstetric fistula, an indicator of poor delivery practices. Though progress has been made, only 40% of women who gave birth in the five years preceding the survey received antenatal care from a skilled provider for their most recent birth compared to 28% in 2005. (EMDHS 2014)

Family Planning: The proportion of women using modern family planning methods has increased more than six fold, from 6% in 2000, to 40% in 2014 (EMDHS, 2014). The fertility rate decreased to 4.1 as reported in 2014, from 5.5 in 2000, yet there are substantial differences between urban and rural areas and among the regions. Furthermore, many years of very high fertility and low contraceptive prevalence contribute to an annual population growth rate of 2.6%. This high population growth puts tremendous pressure on arable land as well as all social services including education, health and employment opportunities.

HIV/AIDS: According to UNAIDS (2012), Ethiopia’s adult prevalence rate is estimated at 1.3%, which is consistent with 2012 HIV epidemiological projections for Ethiopia. While HIV prevalence is low, with a significantly declining incidence, the burden of the disease is still high due to the population size, expanding

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urbanization, increased mobility due to employment seeking, and very high levels of internal migration. Conflicting signs indicate that stigma still adversely affects prevention efforts, while violence and discrimination against most-at risk-populations (MARPs) impacts the enabling environment. Cross-generational sex, gender-based violence, transactional sex, divorce, high-risk migration, and the lack of user friendly preventive clinical services are all crucial drivers of the epidemic in Ethiopia. Though Prevention of Mother to Child Transmission (PMTCT) services have increased significantly since the scale up in 2003, only about 64% of public hospitals and health centers provide Antenatal Care (ANC), and among those receiving ANC, less than 70% were tested for HIV according to the 2014 Country Progress Report on the HIV Response. While PMTCT services in rural areas is resource intensive, there is also low utilization where PMTCT services do exist and high loss to follow-up - approximately three quarters of identified HIV positive women and even fewer of their HIV-exposed infants received ARV propylaxis, while only 9.5% of HIV positive children received ART (2014 Country Progress Report). Prevalence in urban areas has fallen from 7.7% per the 2005 DHS to 4.2% (up to 5.2% in Addis Ababa), but no such declines have been observed in rural prevalence, which stands at 0.6%. Moreover, there is emerging evidence that small towns and transportation corridors are becoming “hot spots” for new infections, and there is considerable variation in terms of geographic and sub-population distribution from 2.4% in the Somali region to 9.9%, 10.7% and 10.8% in the Amhara, Tigray and Afar regions respectively.

Tuberculosis: TB has been recognized as a major public health problem in Ethiopia since the 1950s, with one third of the population infected. According to the 2014 WHO Global TB Report, Ethiopia ranks seventh among the 22 high burden countries for TB, with a prevalence of 200/100,000 and incidence of 210/100,000 cases per year respectively. TB is the most common opportunistic illness and a leading cause of death among people living with HIV (PLHIV). Approximately 11% of TB patients are HIV-infected, and 1,400 multi-drug resistant TB (MDR-TB) cases are expected per year (WHO 2014). Moreover, according to the 2013 HSDP IV Annual Performance Report, the TB case detection rate was 58.9%, below the detection rate estimated in the 2011 TB prevalence survey (72%) as well as below the target set for the year (82.7%). As of 2013, the current national TB treatment success rate (TSR) is estimated to be 91.4% while the cure rate for the year 2012/2013 was 70.6%. Although there are improvements in TB control activities, more efforts are still required for Ethiopia to achieve the global targets for Case Detection Rate (CDR).

Malaria: Over 50 million people (60% of the total Ethiopian population) live in areas at risk of malaria as of 2014. According to the Federal Ministry of Health (FMOH), in 2011/2012, malaria was the leading cause of outpatient visits, accounting for 17% of all outpatient visits, and 8% of health facility admissions among all age groups. Malaria is one of the top ten causes of inpatient deaths among children less than five years, as well as adults, according to the Health Management Information System (HMIS) data. Children less than 5 years of age sleeping under ITNs increased from 2% in 2005 to 38% in 2011, but is still far below the target of 80%. Widespread insecticide resistance is a serious threat to vector control efforts in the country. Though large scale malaria epidemics have been averted since 2003/2004, sporadic malaria epidemics, as well as variations in malaria burdens from year to year, result in challenges in preventing stock-outs of antimalarial medications and malaria rapid diagnostic tests (RDTs) within communities.

Water and Sanitation: The Joint Monitoring Program - WHO/UNICEF 2013, showed that 52% of the population has access to improved water sources while only 24% of households have access to improved sanitation facilities. According to the National WASH Inventory Report (2012), only 31% of health facilities (health centers and health posts) have access to an improved water supply and nearly 70% of schools have no access to improved water supplies or sanitation facilities. Consequently, adherence to correct hygiene behaviors, such as washing hands at key times, safe handling and storage of drinking water, and point of use water treatment, is extremely difficult to achieve.

Orphans and Vulnerable Children (OVC): It is estimated that there are 4.5 million orphans in Ethiopia, 900,000 due to AIDS (UNICEF, 2012). Overall, orphan girls suffer more than boys by not being able to attend school, having to care for others, and being forced into early marriage. Many live on the streets in poverty due to insufficient resources and limited skills which results in lifelong trauma and humiliation. Ethiopia has an estimated 77,000 child-headed households. All of these orphans and vulnerable children are at increased risk for neglect, abuse, malnutrition, poverty, illness and discrimination and – as they get older, are much more vulnerable to HIV infection.

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As Africa’s second most-populous country, Ethiopia has a large, predominantly rural (82%), and impoverished population. While there have been significant improvements, the population as a whole still has poor access to clean water and sanitation, marginal access to and/or utilization of quality health services, low literacy levels, and persistent food insecurity. These factors contribute to a high incidence of communicable diseases including TB, HIV/AIDS, malaria, Neglected Tropical Diseases (NTDs), and respiratory infections, as well as nutritional deficiencies and some of the world’s highest rates of maternal, neonatal, and child mortality.

2.2 National Environmental Policies and Procedures

GFDRE Environmental Management The system of Government of the Federal Democratic Republic of (GFDRE) is quite decentralized. The country follows a parliamentarian form of government. The Federal GFDRE consists of nine National Regional States (NRSs) delimited on the basis of the settlement patterns, language, identity and consent of the concerned communities (Articles 45, 46, 47 of the Federal Constitution). Within the NRSs there are zonal and woreda (District) administrative levels, with the woredas being the important levels where local self-government is exercised.

According to the Federal Constitution, all powers not given expressly to the Federal government alone or concurrently with the NRSs are reserved to the states. Thus, the states have the power to enact and execute their own constitution and other laws as well as formulate and execute their economic, social and development policies, strategies and plans. However, they can only administer land and other natural resources in accordance with Federal laws (Article 52). They have the power to collect royalty from forest resources as well as share royalty form mining and gas and petroleum operations with the federal government.

The Woreda’s powers include examining and approving draft economic development, social services as well as working plans and programs. In particular they are responsible for following up on agricultural development activities that are undertaken consistent with the appropriate season and that conservation and care of natural resources is carried out with special attention.

In general, the decentralized system is expected to facilitate environmental management through ensuring the political, economic and social empowerment of citizens at all levels. This is particularly important for community and village levels to enable them to lead developments in their areas.

Besides the overall mandate of the Federal government to formulate and implement the country’s policies, strategies and plans in respect to overall economic, social and development matters, there are, among others, specific provisions in the Federal Constitution which specify Federal mandates over natural resources. These include the protection and preservation of cultural and historical legacies and enacting laws for the utilization and conservation of land and other natural resources, historical sites and objects as well as the power to determine and administer the utilization of the waters or rivers and lakes linking two or more states or crossing the boundaries of the national territorial jurisdiction (Article 51). In addition, the Federal constitution enshrines the important principle that “all persons have the right to a clean and healthy environment and that all persons who have been displaced or whose livelihoods have been adversely affected as a result of state programs have the right to commensurate monetary or alternative means of compensation, including relocation with adequate state assistance” (Article 44(1)).

Environmental Policy and Regulation

At the Federal level there is the Environmental Policy of Ethiopia (EPE). The elements included in the policy are extracted from the Conservation Strategy of Ethiopia (CSE) completed in year the 2001. The CSE was formulated with the intention of bringing about sustainable management of natural resources in the context of development. The policy is the result of a process of identifying and agreeing on the major environmental issues through discussions in a series of workshops and conferences and meetings with representative communities at the grass roots level. The policy is designed to integrate environmental concerns into

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development in a manner that will bring about a holistic management approach with the objective of improving human and ecological conditions and making the transition to a sustainable society.

Some of the major components of the EPE with direct relevance to activities planned under USAID SO 14 concern water resource management and women’s policy. These topics are covered briefly below:

Water Resources Management : The planning and development unit for water resources is the drainage basin and priority is to be given to watershed management to control and conserve water and to regulate its balance in the catchments. Integrated Water Resources Management (IWRM) which emphasizes multi-purpose projects isadopted. The Policy also gives recognition to the fact that natural ecosystems, particularly wetlands and upstream forests, as well as the interface between water bodies and land (e.g., lake shores, river banks and wetlands) are fundamental in regulating water quality and quantity and to integrate their rehabilitation and protection into the conservation, development and management of water resources.

Planning of surface and ground water uses, artificially recharging ground water aquifers, recycling water and not exceeding the sustainable water supply in the course of water allocation are some of the policy measures designed to maximize efficient use of the quantity and to improve the quality of water.

There are also several policy prescriptions with regard to the protection of water and related flora and fauna from harmful effects such as the introduction of exotic species into water ecosystems. Furthermore, the design, construction and use of dams and irrigation systems and other water works should ensure the control of environmental health hazards.

Currently, sectoral water resources development and protection policies, strategies and water resources development action plans (including drinking water and sanitation) are in place. In order to meet human and financial needs of the water sector, the Arba Minch Water Technology Institute and a Federal-level water fund have been established.

It should be noted that the National Regional States have their own Regional Conservation Strategies tailored to their specific needs but consistent with the EPE and the Conservation Strategy of Ethiopia.

The Women’ s Policy : This policy is the first comprehensive and official policy on the question of women. It is designed to facilitate the way for women to liberate themselves from social and economic discrimination and make possible affirmative actions to be taken to redress past imbalances between the sexes. In addition to the women’s policy itself, the various policies and strategies briefly described above attempt also to take into account and acknowledge, among others, women’s important role in environmental management.

Despite the obvious effort to put important policies in place there are still some serious gaps in the natural resources policy area. For example, although there are draft policies for some natural resources sub-sectors (e.g., forestry, wildlife, soil conservation, land use), no measure has been taken to approve and operationalize these draft policies. Ideally following the finalization of the Conservation Strategy of Ethiopia (CSE) and the Regional Conservation Strategies (RCSs) sectoral policy review should have commenced for harmonizing existing policies with the Environmental Policy of Ethiopia (EPE) as well as filling gaps where they existed.

Government, having put polices and strategies in place, is now facing the challenge of effectively commendable translating them into concrete action on the ground in terms of community level program and projects designed to meet the urgent needs of the poor as well as sustainable use of the environmental resources of the country.

Other Relevant GFDRE Environmental Laws

Below is a description of the most important environmental laws at the Federal level.

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Establishment of Environmental Protection Organs Proclamation (No. 295 of year 2002 ):

This Proclamation assigns responsibilities to separate organizations for environmental development on the one hand, and environmental protection, regulation and monitoring on the other, avoiding possible conflicts of interests and duplication of efforts. It is designed to be instrumental in the sustainable use of environmental resources and fosters a coordinated and yet distinct responsibility between and among environmental agencies at federal and regional levels.This Proclamation repeals the EPA establishment Proclamation No. 9 of year 1995. It provides for the re- establishment of the EPA, which is accountable to the Prime Minister. In addition, it provides for the Establishment of an Environmental Protection Council as well as sectoral agencies and Environmental units.

Pursuant to this Proclamation, each relevant government organization shall establish under it environmental units the responsibility to ensure that its activities are being carried out in a manner which is compatible with the environmental law and obligations emanating there from. In addition, the Proclamation entrusts environmental organs to be established by the regions with extensive mandates that enables the coordination of environmental activities, avoids duplication and improves the dissemination of environmental information.

Environmental Pollution Control Proclamation (Number 300, dated 2002) :This Proclamation was enacted to help realize the effective implementation of the environmental objectives and goals incorporated in the Environmental Policy of Ethiopia (EPE). In addition the Proclamation was enacted for the reasons indicated below.

Some of the social and economic development endeavors may be capable of causing environmental impacts that might be detrimental to the development process itself;

The need to protect the environment in general and particularly safeguard human health and well-being, preserve the biota and maintain an untainted aesthetics is the duty and responsibility of all; and

It is essential to prevent or minimize the undesirable pollution resulting from economic development through appropriate measures.

The Proclamation consists of a number of articles on different issues such as pollution control, management of hazardous wastes, chemicals and radioactive substances, environmental standards, the rights and duties of environmental inspectors and penalties.

Environmental Impact Assessment Proclamation (Number 299, dated 2002) :

The main reasons for enacting this Proclamation are indicated below. Environmental Impact Assessment serves to bring about thoughtful development by predicting

and mitigating the adverse environmental impacts that a proposed development activity is likely to cause as a result of its design, location, construction, operation, modification and cessation.

A careful assessment and consideration of the environmental impacts of public documents prior to their approval, provides an effective means of harmonizing and integrating environmental, economic, social and cultural considerations and aspirations into the decision-making process in a manner that promotes sustainable development.

Implementation of the environmental rights and objectives enshrined in the Constitution requires the prediction and management of likely adverse environmental impacts, ways in which the benefits might be maximized, and the balancing of socio-economic benefits with environmental costs.

Environmental impact assessment serves to bring about administrative transparency and accountability, as well as involve the public and, in particular, communities in development planning decisions which may affect them and their environment.

The enactment of these Proclamations will help much in the effort to bring about sustainable development in the country by ensuring that development programs, projects and activities do not cause negative impacts on the natural resource base and the environment in general. The Environmental Protection Authority has also in draft form, effluent and ambient standards for water, air, soil and noise as well as draft regulations to facilitate the implementation of the Pollution Control Proclamation with respect to pollution from industrial

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waste. However, the draft regulations have yet to be approved and enacted and the standards have yet to be backed by legislation to effectively support the implementation and enforcement of the Proclamations described above.

The rate at which laws and regulations required for ensuring compliance with and enforcement of the EPE requirements have been enacted has been rather slow. For example, it is only recently that Environmental Impact Assessment (EIA) has received legal backing with the issuance of Proclamation Number 299 of year2002. It is worthwhile noting, however, despite the lack of a full-fledged EIA legislation, EPA has been involved in reviewing EISs of proposed development projects submitted to it by the Ethiopian Investment Authority and a few other government organizations.

The revision of existing sectoral laws to ensure harmony with the Environmental Policy of Ethiopia (EPE) and the drafting and enacting of new laws and regulations has been also been too slow. Again, this is an undertaking that should have commenced immediately after the approval of the EPE and continued at a far urgent rate than is being observed. As a result of these delays, the commencement of requiring compliance and enforcement with the EPE prescriptions has yet to begin. In the mean time actions that may result in serious damage to the environment will continue unabated.

Again, no systematic evaluation and review of sectoral environmental legislation has been made. For example, the wildlife sector is still governed by an old and outdated legislation. Although the legislation governing the forest sector has been revised in 1994 with the intention of updating it (mainly in terms of providing for new types of forest ownership), it has not yet been evaluated for the consistency of its provisions with the new policy prescriptions and legal norms.

Other Federal Laws Related to the Environment and Health Sectors

Labor Proclamation No. 45 of year 1995. Investment Proclamation No. 37 of year 1996. Commercial Registration and Business License Proclamation No. 67 of year 1997. Water Resources Management and Administration Proclamation No. 197 of year 2000. Environmental Health Proclamation No. 200 of year 2000. Radiation Protection Authority Establishment Proclamation No. 79 of year 1993. Urban Zoning and Construction Permit Proclamation.

III. POTENTIAL ENVIRONMENTAL IMPACTSThe main possibility for causing unintended harm to the biophysical environment or human health arises from bio-hazardous healthcare waste management practices in the many types of VCT and PHC facilities to be supported in the selected provinces, local health districts and municipalities.The key intervention categories that are likely to have potential harm under the updated strategy include the following:

Generation, storage and disposal of Special Medical Wastes , e.g. HIV testing, TB testing and laboratory-related activities

Procurement, storage, management and/or disposal of public health commodities, including pharmaceutical drugs, medical kits, supplies and/or chemical reagents;

Long Lasting Insecticidal Nets Small-scale construction/rehabilitation of health facilities; Small-scale water supply and sanitation; Nutrition and nutrition commodity management

1. Generation, storage and disposal of Special Medical Wastes , e.g. HIV testing, TB testing and laboratory-related activities

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Although healthcare activities provide many important benefits to communities, they can also unintentionally do harm via poor management of the waste generated. This waste generally falls into three categories in terms of public health risk and recommended methods of disposal:

General healthcare waste, similar or identical to domestic waste, including materials such as packaging or unwanted paper. This waste is generally harmless and needs no special handling; 75–90% of waste generated by healthcare facilities falls into this category, and it can be burned or taken to the landfill without any additional treatment.

Hazardous healthcare waste including infectious waste (except sharps and waste from patients with highly infectious diseases), small quantities of chemicals and pharmaceuticals, and non-recyclable pressurized containers. All blood and body fluids are potentially infectious.

Highly hazardous healthcare waste, which should be given special attention, includes sharps (especially hypodermic needles), highly infectious non-sharp waste such as laboratory supplies, highly infectious physiological fluids, pathological and anatomical waste, stools from cholera patients, and sputum and blood of patients with highly infectious diseases such as TB and HIV. They also include large quantities of expired or unwanted pharmaceuticals and hazardous chemicals, as well as all radioactive or genotoxic wastes.

Potentially infectious waste: Improper training, handling, storage and disposal of the waste generated in health care facilities or activities can spread disease through several mechanisms. Transmission of disease through infectious waste is the greatest and most immediate threat from healthcare waste. If waste is not treated in a way that destroys the pathogenic organisms, dangerous quantities of microscopic disease-causing agents—viruses, bacteria, parasites or fungi—will be present in the waste. Although sharps pose an inherent physical hazard of cuts and punctures, the much greater threat comes from sharps that are also infectious waste. Healthcare workers, waste handlers, waste-pickers, substance abusers and others who handle sharps have become infected with HIV and/or hepatitis B and C viruses through pricks or reuse of syringes/needles.

Contamination of water supply from untreated healthcare waste can also have devastating effects. If infectious stools or bodily fluids are not treated before being disposed of, they can create and extend epidemics. The absence of proper sterilization procedures is believed to have increased the severity and size of cholera epidemics in Africa during the last decade.

2. Procurement, storage, management and/or disposal of public health commodities, including pharmaceutical drugs, medical kits, supplies and/or chemical reagents

Pharmaceutical drugs including vaccines have specific storage time and temperature requirements, and may expire or lose efficacy before they are used, particularly in remote areas where demand is low and/or infrequent. Pharmaceutical waste may also accumulate due to inadequacies in stock management and distribution and/or lack of a routine system of disposal.

The effects of pharmaceutical waste in the environment are different from conventional pollutants. Drugs are designed to interact within the body at low concentrations to elicit specific biological effects in humans, and which may also cause biological responses in other organisms. There are many drug classes of concern, including antibiotics, antimicrobials, antidepressants, and estrogenic steroids. Their main pathway into the environment is through household use and excretion, and through the disposal of unused or expired pharmaceuticals.

Effects on aquatic life are a major concern in disposal of pharmaceuticals. A wide range of pharmaceuticals have been discovered in fresh and marine waters globally, and even in small quantities some of these compounds have the potential to cause harm to aquatic life.

Additional health risks related to disposal include burning pharmaceuticals and plastic medical supplies (including new or used condoms) at low temperatures or in open containers results in release of toxic pollutants into the air. Inefficient and insecure sorting and disposal may allow drugs beyond their expiry date to be diverted for resale to the general public.

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3. Use of Long Lasting Insecticidal Nets (LLINs)With respect to LLINs, the distribution of LLINs has been shown to be a cost-effective and efficacious approach to malaria vector control in many situations, and as such provides significant public health benefits. Along with these benefits, however, the use of these treated materials with insecticides creates tangible risks to human health and the environment throughout the life cycle of the insecticide products. Continuous exposure to LLINs may have some risks that need to be monitored over time. In addition to concerns regarding distribution and use of LLINs, disposal of bed nets, particularly by burning, can result in adverse environmental and human health effects. Adverse health effects also arise from conversion of LLINs to improper use (e.g. use as fishnets, clothing, and wrapping.) These issues have been considered and mitigation measures specified in USAID’s Malaria Vector Control Programmatic Environmental Assessment (MVC PEA).

4. Small Scale Construction /Rehabilitation of health facilitiesHealth services usually leads to construction and/or rehabilitation of facilities at various potential scales (i.e., very small scale, small scale, large scale) with the aim to expand capacity for health care delivery, including facilities delivering healthcare services and those supporting the supply chain (e.g., warehouses, etc.) usually have construction and operational impacts on environment. For example, this may include construction/rehabilitation of facilities to expand capacity to provide HIV/AIDS services, maternal and child health services, and/or storage facilities for health care commodities, among others. Small-scale healthcare facilities play a vital role in public health and are a key part of integrated community development. However, environmentally poor design and management of these facilities can adversely affect patient and community health countering the very benefits they are intended to deliver. Many, but not all, of the potential environmental impacts and consequent health risks posed by health care facilities are associated with healthcare wastes and their management. Healthcare waste includes all waste generated by the health care activities of a healthcare facility. Much of this is general waste, and is similar or identical to domestic waste. The remainder is hazardous or highly hazardous and includes hypodermic needles, syringes, soiled dressings body parts and fluids (including blood), diagnostic samples, diapers, laboratory cultures, chemicals, pharmaceuticals, medical devices, batteries, and thermometers. These wastes either pose risks of infection or present chemical hazards.

Biological and chemical contamination of ground and surface water may result from poorly sited, designed, and managed latrines, septic and wastewater systems and waste pits. Contamination can occur through overland flow into surface waters, seepage into ground water, or by direct disposal into waterways. Poor design facilitates the spread of pathogens, e.g from poor siting of facilities like latrines and lack of screening of the latrines openings. Besides hazardous wastes, clinics generate a variety of solid wastes including organic materials, papers and packaging, empty containers from cleaning products, and other miscellaneous wastes. Other risks may be associated with toxic or nuisance air pollution from open pit burning of waste, open or improper disposal of sharps, pesticide spills and exposures, asbestos contamination and exposure in older facilities.

Poor designs may pose risks to patients, visitors and staff. These may include lack of sterilization, inadequate or contaminated water supply, poor design leading to cramped waiting areas, insufficient air circulation, and damp conditions, as well as inadequate barriers (fences, screens and nettings to prevent livestock, insects and birds from wondering into the clinic facilities).

5. Small-scale water supply and sanitationWhile water and sanitation projects are intended to improve environmental and public health (and provide numerous other benefits), when managed ineffectively they may cause adverse impacts that can offset or eliminate the intended benefits. Good sanitation and hygiene practices are essential to prevent contamination of water resources. Water supply and sanitation projects and hygiene promotion should be viewed as interdependent activities.

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Water supply and sanitation projects may cause increased incidence of infectious water-borne diseases such as cholera, non-infectious disease such as arsenic poisoning, and water-enabled diseases such as malaria, schistosomiasis4 or bilharzia.

Poor design, operation and/or maintenance of water supply improvements can lead to pools of stagnant water near water taps, water pipes and storage tanks. Improper or ineffective practices for disposing of excreta and solid waste can exacerbate this problem. Stagnant water pools form an excellent breeding place for disease vectors (mosquitoes that carry malaria, etc.). They can also increase transmission of water-related diseases, especially when the wet spots are clogged or contaminated with solid waste or excreta.

Contamination of surface and groundwater supplies with infectious organisms from human excreta is especially serious. Contamination may be caused by poorly designed, operated or maintained sanitation facilities.

Infectious diseases may also be spread by improper use of wastewater to grow food crops. Failure to test new sources of water, especially groundwater, for possible natural or industrial chemical

contaminants, such as arsenic, mercury, fluoride and nitrate, can lead to serious health problemsOther potential risks arising from poorly designed water supply projects may include depletion of fresh water resources, chemical degradation of the quality of potable water sources, creation of stagnant water (leading to increased vector borne diseases, soil erosion and sedimentation and health related issues due to contamination) supply of contaminated water leading to arsenic and mercury poisoning and water related infections.

Sanitation projects, on the other hand, may pose risks relating to contamination of surface water, ground water, soils and food by excreta, chemicals and pathogens. Large scale sanitation projects or cumulative small scale projects may lead to degradation of streams, lakes, and degradation of land habitats.

6. Small Grants ProgramsAn often used methodology to get programming to the community level is through a small grants program, administered via CBOs, NGOs, and FBOs, to provide, for example, palliative care to vulnerable households, and for developing and implementing community/home-based care skills and programs (training for caregivers, especially for victims of AIDS or chronic illness). Small grants may be provided for community governance structures (training to strengthen or establish community health committees or hospital boards) b) support for youth organizations in prevention of HIV/AIDS/STDS and TB (educational materials, workshops, counseling).

Small grants may lead to awards that may represent biophysical interventions that are not analyzed in the above sections of this IEE. These grants may therefore pose risks different from the those analyzed in this section.

7. Nutrition commodity management including packaging, warehousing and distributionNutrition commodity management often times includes packaging, warehousing and distribution. The process may include protection against pests through fumigation, packaging and repackaging. The use of fumigation using toxic pesticides is of concern because of the risks involved in handling, procuring and and use of pesticides. Pesticides can endanger human and animal health, persist in nature, and interfere with natural pesticide controls (such as predatory insects). Applying too many agrochemicals can cause many of these elements to build up in water.

IV. RECOMMENDED THRESHOLD DETRMINATION, CONDITIONS FOR IMPLEMENATION AND MITIGATION MEASURES

4.1 THRESHOLD DETRMINATIONSSummary of Recommended Determinations

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Key Elements of Program/Activities Threshold Determination & 22 CFR 216 Citation

Increased Use of Health, Water and Sanitation Services Promote the GFDRE Community Health Extension

Package; expand the number of community-based reproductive

health agents and integrate more closely with the public system;

mobilize communities through the Champion Community approach to promote family planning, child health, nutrition, water and sanitation, and girls education and food security and safety net initiatives;

promote the Essential Nutrition Action package of interventions (vitamin A, iodine, breastfeeding, appropriate complementary feeding, care of the sick child and women’s nutrition);

strengthen health and nutrition interventions to support people living with AIDS;

promote the Child-to-Child School Health program with involvement of parent associations;

promote community health councils to support routine as well as emergency health response needs; and

Promote household level sanitation and hygiene behaviors.

Categorical Exclusion, per 22CFR216.2(c)(2): (i) Education, technical assistance, training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.);(iii) analyses, studies, workshops and meetings(v) document and information transfer(viii) p r o g r a m s i n v o l v i n g nutrition, health care or population and family planning services except to the extent designed to include activities directly affecting the environment (such as construction of facilities, water supply systems, waste water treatment, etc.);(xi) maternal or child feeding conducted under Title II of Public Law 480; and(xiv) Programs to develop capability of recipient countries and organizations in development planning.

expand t h e number of protected community water supplies.

A Negative Determination with Conditions is recommended pursuant to 22 CFR 216.3(a)(2)(iii),

Support to health delivery and management system strengthening institutional capacity to plan for and

manage health commodity needs, including the formulation of a national plan for contraceptive security;

developing logistics management tools for procurement and management of health products;

Categorical Exclusion per 22CFR216.2(c)(2.:(i) Education, technical assistance, training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.) ;(iii) analyses, studies, workshops and meetings(v) document and information transfer

pre-positioning essential commodities in drought vulnerable areas

supporting the expansion of Special Pharmacies building health service delivery sites through cash for

work


Health Services Quality improvement linking community health workers to social marketing of

essential health products; technical support to develop and implement sub-sectoral

policies, guidelines and protocols;

Categorical Exclusion per 22CFR216.2(c)(2),:(i) Education, technical assistance, training programs except to the extent such programs

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improve regional and woreda health bureau capacity to provide supportive supervision;

incorporate emergency health response training in public health curriculum;

assure that nutrition is included in the care of HIV clients; assure that appropriate referrals are made to link HIV

positive clients with family planning programs.

include activities directly affecting the environment (such as construction of facilities, etc.);(iii) analyses, studies, workshops and meetings(v) document and information transfer(viii) p r o g r a m s i n v o l v i n g nutrition, health care or population and family planning services except to the extent designed to include activities directly affecting the environment (such as construction of facilities, water supply systems, waste water treatment, etc.);((xiv) Programs to develop capability of recipient countries and organizations in development planning.

supporting routine immunization services, with particular emphasis on the cold-chain and polio, measles and tetanus toxoid;


increasing the sustainable availability of insecticide- treated bednets through the engagement of the local commercial sector;

supporting a national social and commercial marketing program for selected products such as bednets, condoms, and contraceptives;

Negative Determination with Conditions for activities to increase access and use of long- lasting insecticidal Nets (LLIN). Does not cover treatment or retreatment of nets. See table 3 for conditions

Health Sector Resources and Systems Improvement strengthening the national Integrated Disease

Surveillance and Response System; strengthening the Health Management Information System;

supporting the development of an Emergency Early Warning System that synthesizes data from various sectors to predict emerging crises;

building capacity in health care resource planning and budgeting; supporting the implementation of the national Health Care Financing Strategy;

promoting contingency planning for essential drugs and other products for crisis situations (pre-positioning);

supporting the Ministry of Health to build capacity for addressing acute vulnerabilities; and

Supporting the government’s Emergency Nutrition Coordinating Unit (ENCU) to manage a nutrition surveillance system and to respond to nutrition emergencies, integrating these approaches with the Ministries of Agriculture and Rural Development.

Categorical Exclusion, per 22CFR216.2(c)(2): (i) Education, technical assistance, training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.);(iii) analyses, studies, workshops and meetings;(v) document and information transfer; and(xiv) Programs to develop capability of recipient countries and organizations in development planning.

establishing a voucher system for insecticide-treated bednets (ITNs) based on the commercial sector (safety net);

Negative Determination with Conditions for activities to increase access and use of long- lasting insecticidal Nets (LLIN). Does not cover treatment or retreatment of nets. See table 3 for conditions

HIV/AIDS prevalence reduction and mitigation of the impact of HIV/AIDS

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strengthening and developing HIV/AIDS education programs through school, church and community anti- AIDS clubs, sports clubs and workplace intervention programs in targeted areas;

developing and implementing life skills training, vocational skills training and workplace programs for targeted groups;building on USAID/Ethiopia’s successful social marketing program to expand access to condoms; and

Coordinating and supporting risk reduction HIV/AIDS activities across USAID/Ethiopia programs.

Categorical Exclusion, per 22CFR216.2(c)(2): (i) Education, technical assistance, training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.);(iii) analyses, studies, workshops and meetings; and (v) document and information transfer

expanding the national provision of voluntary counseling and testing (VCT) and follow up services such as post-test clubs

A Negative Determination with Conditions is recommended pursuant to 22 CFR 216.3(a)(2)(iii) is recommended for expanded provision of VCT services.

Mother-to-child transmission of HIV reduction program developing federal, regional and facility capacity to

develop PMTCT and PMTCT Plus services through training, systems strengthening, improved guidelines and monitoring and evaluation;

Categorical Exclusion, per 22CFR216.2(c)(2): (i) Education, technical assistance, training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.); and (v) document and information transfer

supporting site-specific implementation of PMTCT and PMTCT Plus services; and

improving community level partnerships to achieve comprehensive coverage.

A Negative Determination with Conditions is recommended pursuant to 22 CFR 216.3(a)(2)(iii)Activities may involve testing and therefore contaminated blood handling, used syringes, sharps, etc

Access to care and treatment for people living with HIV and AIDS increased developing federal, regional and facility capacities to

deliver care and treatment services through training, provision of guidelines and materials, systems strengthening and infrastructure development;

promoting and strengthening community skills and community-based response and support organizations…to provide psychosocial support to people living with HIV and AIDS;

mobilizing and collaborating with civil society …to improve support to HIV infected and affected individuals;

developing mechanisms to provide food and nutritional support that links to Title II resources to individuals, families and communities affected by HIV/AIDS;

mobilizing and collaborating with civil society …to improve support to HIV infected and affected individuals

Categorical Exclusion, per 22CFR216.2(c)(2): (i) Education, technical assistance, training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.);(v) document and information transfer(xi) maternal or child feeding conducted under Title II of Public Law 480; and(xiv) Programs to develop capability of recipient countries and organizations in development planning.

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working with CDC-Ethiopia to support the national provision of ARVs and associated support services;

improve treatment for Opportunistic Infections and Sexually Transmitted Infections;

coordinating and supporting care and treatment activities across USAID/Ethiopia programs.

A Negative Determination with Conditions is recommended pursuant to 22 CFR 216.3(a)(2)(iii)Activities may involve testing and therefore contaminated blood handling, used syringes, sharps, etc

Care and support for orphans and vulnerable children expanded improving the data on and advocacy for orphans and

vulnerable children; improve the capacity of communities to support orphans,

vulnerable children and their families.

Categorical Exclusion, per 22CFR216.2(c)(2): (i) Education, technical assistance, training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.); and(v) document and information transfer

coordinating and supporting orphan and vulnerable children activities across USAID/Ethiopia programs

supporting programs to extend the length and quality of life of parents living with HIV and AIDS

enhancing long-term food security for children and their families, through development of economic capacities;

Negative Determination with Conditions, 22 CFR 216.3 (a)(2)(iii)

A more supportive environment for responding to HIV/AIDS expanding ongoing work in policy and advocacy both with

government, the private sector, faith-based and community-based organizations;

developing and supporting effective drug and key commodity procurement, management and distribution systems;

maintaining and implementing an ongoing demographic, social science and program research agenda, which addresses critical gaps in knowledge and emerging issues;

continuing to participate in HIV/AIDS donor forum to improve coordination among donors and between donors and government partners;

strengthening the coordination of USAID/Ethiopia implementing partners programs to ensure consistent approaches and maximum coverage; and

coordinating and supporting HIV/AIDS impact assessments and research activities across USAID/Ethiopia’s sector programs.

Categorical Exclusion, per 22CFR216.2(c)(2): (i) Education, technical assistance, training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.);(iii) analyses, studies, workshops and meetings(v) document and information transfer

4.2 MITIGATION MEASURES AND CONDITIONS FOR IMPLMENATION

Table 3: Mitigation measures/conditions for implementationActivity Category Mitigation measures or Conditions for implementation

1. Training/supportive supervision/ curricula

Any training activities for professional health workers or community health workers involving techniques that would generate and require disposal of

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development in the areas of HIV/AIDS, MNCH, palliative care, and hygiene and sanitation, methadone substitution therapy services

hazardous or highly hazardous waste (e.g. sharps, afterbirth from delivery, waste from screening for HIV or STIs.) must include training in or ensure that the training curriculum covers best management practices concerning the proper handling, use, and disposal of medical waste, including blood, sputum, and sharps.Note that this condition applies to activities targeting home care AND community health workers, not just those in clinics and health facilities. Wherever relevant, appropriate disposal mechanisms in home-based and community-based situations that are cost effective and safe must be identified and appropriately incorporated in training, protocols, and guidelines. This includes training home care and community health workers to deliver positive messages about personal and household hygiene, sanitation, and proper disposal of condoms and other potentially harmful materials.

2. Activities involving generation, storage and disposal of Special Medical Wastes , e.g. HIV testing, TB testing and laboratory- including activities which might entail blood handling, injections or other generation of healthcare waste, such as for the components of any HIV/AIDS Reproductive Health, Primary Health Care, Anti-retroviral (ARV), and immunization interventions that directly or indirectly result in the generation and disposal of bio-hazardous health care waste.

HIV/AIDS/STD and TB prevention and treatment activities could directly or indirectly involve testing and therefore contaminated blood handling, used syringes, sharps generation, and disposal of medical waste. PEPFAR programs is expected to deal with most of these matters directly.

It is recommended that the Health Team work with its implementing partners to assure that the medical facilities and operations involved have adequate procedures and capacities in place to properly handle, label, treat, store, transport and properly dispose of blood, sharps and other medical waste.

The USAID’sSector Environmental Guidelines ‘Healthcare Waste: http://www.usaidgems.org/Documents/SectorGuidelines/Healthcare contains guidance which should inform the Team’s activities to promote proper handling and disposal of medical waste, particularly in the section titled, “Minimum elements of a complete waste management program.” (Attached as Annex A).

The PEPFAR Country Operations Plan for Ethiopia contains considerable detail in squarely addressing the very issues raised herein. It includes activities to be carried out for the following sorts of FY 04 PEPFAR Objectives in Ethiopia, with the Agency carrying them out: PMTCT, Blood Safety, Safe Injections, VCT, Palliative Care, Support for Orphans and the Vulnerable; Anti-Retroviral Therapy, Laboratory Support. Through the SO 14.2 PEPFAR program, one can be confident that potential for harm to the environment and human health will be minimized. The only issue that may not be dealt with directly is that of proactive disposal of healthcare waste, especially regarding inadequate incineration measures.

Procurement, storage, management, and disposal of public health commodities

In any instance that a USAID project controls commodities at end-of-life, appropriate end-of-life management must be assured.

Otherwise, and in all cases, implementing partners conducting activities involving procurement, storage, management and/or disposal of public health commodities, including pharmaceutical drugs, immunizations and nutritional supplements, must ensure, to the greatest extent practicable, that they and/or

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http://www.usaidgems.org/Documents/SectorGuidelines/Healthcare%20Waste%20Guideline%20Final_w_GCC_Addition_May11.pdf

the medical facilities and operations involved, as appropriate, have adequate procedures and capacities in place to properly manage and dispose of such commodities.

Consignees for any pharmaceutical drugs procured under these activities must be advised: (1) to store the product according to the information provided on the manufacturer’s Materials Safety Data Sheet (MSDS); (2) that, if disposal is required due to expiration or any other reason, the preferred method of disposal is to return to the manufacturer. If that is not possible, then the preferred disposal method is as per the WHO Guidelines for Safe Disposal of Unwanted Pharmaceuticals. (www.who.int/water_sanitation_health/medicalwaste/unwantpharm.pdf) Mandatory references for “appropriate end of life management”: WHO Guidelines for Safe Disposal of Unwanted Pharmaceuticals. www.who.int/water_sanitation_health/medicalwaste/unwantpharm.pdf“Healthcare Waste” chapter, USAID Sector Environmental Guidelines www.usaidgems.org/Sectors/healthcareWaste.htm

Negative Determination subject to the following conditions : Procurement and distribution of TB-related commodities must conform

with the WHO-approved list of drugs and treatment regimens (WHO Standard for Treatment: World Health Organization’s International Standards for Tuberculosis Care (http://www.who.int/tb/publications/ISTC_3rdEd.pdf?ua=1).

Management and Disposal of pharmaceuticals and other supplies for treatment and prevention of TB are subject to the conditions for procurement and waste management conditions set out in #1 aboveA. For LLIN Activities:1. The implicated IP(s) is/are required to purchase and use only WHO-

approved brands of long-lasting treated nets and adhere to all relevant stipulations made in the USAID Malaria Vector Control PEA

Malaria control programs Use of Insecticide Treated Nets (ITNs), and Long-lasting Insecticidal Nets (LLINs)

The use of Insecticide Treated Nets will likely involve the use of pyrethroids, which though of low toxicity to humans, are very toxic to fish, amphibians, arthropods and other aquatic life. The use of ITNs, and LLINs was the subject of the USAID/Ethiopia Pesticide Evaluation Report and Safe Use Action Plan (PERSUAP)(31-Ethiopia1-ITN-PERSUAP USAID/W), whose recommendations are still valid. However at the time it was not known that re-treatable nets would also be distributed under this program, and so the PERSUAP as currently written does not cover mitigating measures for re-treatment. Therefore the PERSUAP has been updated to cover the increasing use of Long-lasting ITNs (LLINs). It is submitted with this IEE. The DO 2 Health Team shall adhere to the recommendations contained in the PERSUAP, summarized here:

The main conditions are as follows: 1. LLINs will increasingly be the net of choice, and are not expected to

require re-treatment, thus greatly reducing any risks associated with their use. However, some conventional nets (those requiring re-treatment) will still be distributed.

2. With conventional nets, which will continue to be in use for several years, educational materials distributed with do-it-yourself (DIY) treatment kits will advise of proper disposal procedures and project

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staff will be trained in using this procedure.3. Activities involving central net treatment will be required to follow World

Health Organization (WHO) ITN recommendations (http://www.who.int/ctd/whopes/relevant.docs.htm).

4. USAID/Ethiopia will ensure the quality and efficacy of the pesticide products and ITNs purchased and that they contain what they are supposed to contain, and that the ITNs are achieving the level of mosquito control required to reduce transmission.

5. USAID/Ethiopia will incorporate environmental questions into general health impact monitoring plan for ITNs.

USAID/Ethiopia will make all appropriate efforts to assure that the packaging, storage, transport and disposal of ITN pesticidesdistributed by its programs comply with WHO Pesticide Evaluation Scheme guidelines, and the USAID PEA for ITNs in Sub-Saharan Africa:

The DO Team is expected to ensure that the recommendations of the Pesticide Evaluation Report and Safe Use Action Plan (PERSUAP) for malaria control using insecticide treated materials in Ethiopia (34Ethiopia2LLITN_PERSUAP_ SO14&SO16, approved 5/21/2004) are implemented.

Small-scale Construction and Rehabilitation

No complicating factors. The site/facility is not within 30m of a permanent or seasonal stream or water body, will NOT involve displacement of existing settlement/inhabitants, has an average slope of less than 5% and is not heavily forested or in an otherwise undisturbed local ecosystem. The facility does NOT deliver health care services, serves as a diagnostic laboratory, or provide practical or lab-based health training. Sites/Facilities violating one or more of these criteria are subject to the determinations and conditions for “small-scale construction”” (immediately below).

2. Construction will be undertaken in a manner generally consistent with the guidance for environmentally sound construction provided in the Small Scale Construction chapter of the USAID Sector Environmental Guidelines. (http://www.usaidgems.org/sectorGuidelines.htm).

At minimum during construction,

(a) Prevent sediment-heavy run-off from cleared site or material stockpiles to any surface waters or fields with berms, by covering sand/dirt piles, or by choice of location. Only applies if construction occurs during rainy season;

(b) Construction must be managed so that no standing water on the site persists more than 4 days;

(c) IPs must require their general contractor to certify that it is not extracting fill, sand or gravel from waterways or ecologically sensitive areas, nor is it knowingly purchasing these materials from vendors who do so;

(d) IPs must identify and implement any feasible measures to increase the probability that timber is procured from legal, well-managed sources.

3. Asbestos. If the presence of Asbestos is suspected in a facility to be renovated, the facility must be tested for asbestos before rehabilitation works begin. Should asbestos be present, then the work must be carried out in conformity with host country requirements, (if any) and in conformity with guidance to be provided by the MIHP team, in consultation with the MEO and REA. All results of the testing for asbestos shall be communicated to the

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C/AOR.

4. Paint. No lead-based paint shall be used, when lead-free paint is used, it will be stored properly so as to avoid accidental spills or consumption by children; empty cans will be disposed of in an environmentally safe manner away from areas where contamination of water sources might occur; and the empty cans will be broken or punctured so that they cannot be reused as drinking or food containers.

5. Waste handling equipment and infrastructure. USAID intervention must result in the facilities’ possessing adequate infrastructure and equipment to appropriately handle the wastes they may generate, including health care waste and appropriate sanitation facilities as per GOK and WHO requirements.

Construction other than very small-scale

For the construction of facilities in which the total surface area disturbed is more than 1000 m2 The conditions are that:

1. The formal AFR subproject/subgrant review process, as set out by the AFR Environmental Review Form (available at http://www.usaidgems.org/Documents/ComplianceForms/AFR/AFR-EnvReviewForm-20Dec2010.doc ) must be completed and approved by the COR/AOR, MEO and REA prior to construction.

2.The IP must assure implementation of any mitigation and monitoring conditions specified by the approved ERF; and,

3. The environmental management conditions established by the ERF process must be generally consistent with the conditions for “very small scale construction” enumerated immediately above and, at minimum, consistent with achieving a “no issues” result under application of the ENCAP Visual Field Guide for Small-Scale Construction. (http://www.usaidgems.org/Documents/VisualFieldGuides/ENCAP_VslFldGuide--Construction_22Dec2011.pdf)

Small-Scale Water & Sanitation Infrastructure (defined as isolated wells, boreholes and latrines such that the total investment in a given community is less than $250,000).:

1. Good-practice design standards must be implemented for new construction and rehabilitation works, generally consistent with USAID’s Sector Environmental Guidelines: Water Supply & Sanitation: http://www.usaidgems.org/Sectors/watsan.htm. These standards must be specified in the EMMP (see Section 4 of this IEE). For water supply, they must include siting of new wells well away from

groundwater contamination sources (e.g. latrines, cesspits, dumps), exclusion of livestock from water points, and prevention of standing water at water supply points.

For latrines, they must include provisions to prevent contamination of water supplies, appropriate choice of latrine type given local environmental conditions (e.g. pit latrines are rarely suitable in locations where the water table is high), provision of hand wash stations, and development and implementation of a system for ongoing latrine cleaning and maintenance

2. Water Quality Assurance Plan. Prior to drinking water provision, the project will prepare and receive approval for a Water Quality Assurance Plan (WQAP). The WQAP will be prepared in consultation with the cognizant AOR/COR and/or Activity Manager. Its purpose is to ensure that all new and rehabilitated USAID-funded sources of

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http://www.usaidgems.org/Documents/VisualFieldGuides/ENCAP_VslFldGuide--Construction_22Dec2011.pdf

http://www.usaidgems.org/Documents/VisualFieldGuides/ENCAP_VslFldGuide--Construction_22Dec2011.pdf

http://www.usaidgems.org/Documents/ComplianceForms/AFR/AFR-EnvReviewForm-20Dec2010.doc

http://www.usaidgems.org/Documents/ComplianceForms/AFR/AFR-EnvReviewForm-20Dec2010.doc

drinking water provide water that is safe for human consumption. The completed WQAP must be approved by: the AOR/COR and/or Activity Manager; the MEO; and the REA.

Once approved, the WQAP must be implemented in full, and for the duration of drinking water activities. Implementation must include testing of water prior to making the supply point available to beneficiaries.

The WQAP constitutes a key element of the project’s EMMP. As with all other elements of the EMMP, project budgets, workplans, and staffing plans must provide for its full implementation. The approved WQAP must include at minimum the following sections:

o Project information (name of project, name of IP, period of performance, contact information, name of COR/AOR)

o A description of the drinking water points to be subject to the WQAP (approximate numbers, water source(s), technology(ies), general geographic area and installation context).

o An inventory of applicable water quality standards, including those promulgated by USAID, as well as the cognizant host-country regulatory entity/entities. (The World Health Organization [WHO] Guidelines for Drinking-water Quality may be substituted for host-country standards that are not accessible, unclear or outdated.)

o The responsible parties/entities/institutions, under host country law or policy, for monitoring and managing water quality of the water points subject to this WQAP. If other than the IP, a summary assessment of their capacity and their involvement.

o A technical assessment of the equipment, resources and expertise that will be required to monitor and report on compliance with applicable water quality standards. This should include, for example, sampling materials, reagents, transportation, storage, laboratory facilities and capacity, communications, training or certification criteria, etc.

o Protocol for initial testing and ongoing monitoring of water quality, to include:

contaminants for which initial testing and ongoing monitoring will be conducted

water quality assessment methods, including test type and frequency

data management and reporting; the project must maintain a central registry of monitoring results by water point and date; GPS coordinates for water points are expected

designation of ‘responsible party’ for each aspect of protocol

response procedures in the event water does not meet water quality standards

o Justification for NOT testing to any applicable standard o Sustainability strategy to the extent that responsibility for

longer-term water quality assurance will transition in part or whole to project partners or beneficiaries. A summary assessment of the capacity of these partners, and any

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capacity building to be undertaken The WQAP should follow any applicable USAID guidance, as well as

local laws, regulations and policies.

3. Capacity-building in equipment/system maintenance must be co-programmed with construction/installation of small-scale water supply and sanitation infrastructure The following types of activities will require mitigating measures to be undertaken: development and rehabilitation of latrines and boreholes; community construction of primary health care centers; rehabilitation of existing health worker training institute structures; and rehabilitation and improvement of water and sanitation facilities in health centers (boreholes and latrines). Some primary healthcare centers may be constructed with food-for-work.

Nutrition commodity management including packaging, warehousing and distribution

All nutrition warehousing activities will be carried out as per the requirements of the USAID Global Fumigation Programmatic Environmental Assessment (PEA) that will be integrated in the workplan, to cater for pesticide use in fumigation. A fumigation PERSUAP authorizing the pesticides in use shall be prepared

Small Grants Programs and DCA activities

The sub-grants and small grants programs have not been defined in any detail. Typically, vulnerable households and children will have access to social grants and support services (e.g., foster care grants, child support grants, disability grants, etc.). Small grants in this context are not used for local governance initiatives which involve infrastructure improvements.

Conditions: In the event that grant support is contemplated for activities with the potential for environmental impact, then an environmental screening process must be introduced. See Section 4 for details.

Lending institutions will incorporate conditions in their DCA guaranteed loan agreements that require borrowers to comply with all applicable local environmental laws and regulations. Lending institutions present to USAID that they will ensure that they (a) adhere to their internal environmental policies, (b) issue sub-loans to borrowers in line with their environmental policies, and (c) that USAID has the right to review the guaranteed lending institutions’ environmental policies.

For those loans that USAID does not reserve rights to review and approve individual loans a Categorical Exclusion is recommended. Pursuant to 22CFR216.2(2)(c)(x), support for intermediate credit institutions when the objective is to assist in the capitalization of the institution or part thereof and when such support does not involve reservation of the right to review and approve individual loans made by the institution.

V. GENERAL PROJECT IMPLEMENTATION AND MONITORING REQUIREMENTS

In addition to the specific conditions enumerated in table 3, the negative determinations recommended in this IEE are contingent on full implementation of the following general monitoring and implementation requirements:

1. IP Briefings on Environmental Compliance Responsibilities. The Health team shall provide each Implementing Partner with a copy of this IEE; each IP shall be briefed on their

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environmental compliance responsibilities by their cognizant C/AOTR. During this briefing, the IEE conditions applicable to the IP’s activities will be identified.

2. Development of EMMP. Each IP whose activities are subject to one or more conditions set out in table 3 of this IEE shall develop and provide for C/AOTR review and approval an Environmental Mitigation and Monitoring Plan (EMMP) documenting how their project will implement and verify all IEE conditions that apply to their activities.

These EMMPs shall identify how the IP shall assure that IEE conditions that apply to activities supported under subcontracts and subgrant are implemented. (In the case of large subgrants or subcontracts, the IP may elect to require the subgrantee/subcontractor to develop their own EMMP.)

(Note : sample EMMP formats are available at www.encapafrica.org/meoEntry.htm.)3. Integration and implementation of EMMP. Each IP shall integrate their EMMP into their project

work plan and budgets, implement the EMMP, and report on its implementation as an element of regular project performance reporting.

IPs shall assure that sub-contractors and sub-grantees integrate implementation of IEE conditions, where applicable, into their own project work plans and budgets and report on their implementation as an element of sub-contract or grant performance reporting.

4. Integration of compliance responsibilities in prime and sub-contracts and grant agreements.a. The Health team shall assure that any future contracts or agreements for implementation of

the project, and/or significant modification to current contracts/agreements shall reference and require compliance with the conditions set out in this IEE, as required by ADS 204.3.4.a.6 and ADS 303.3.6.3.e.

b. IPs shall assure that future sub-contracts and sub-grant agreements, and/or significant modifications to existing agreements, reference and require compliance with relevant elements of these conditions.

5. Assurance of sub-grantee and sub-contractor capacity and compliance. IPs shall assure that sub- grantees and subcontractors have the capability to implement the relevant requirements of this IEE. The IP shall, as and if appropriate, provide training to subgrantees and subcontractors in their environmental compliance responsibilities and in environmentally sound design and management (ESDM) of their activities.

6. Health Team monitoring responsibility. As required by ADS 204.3.4, the FHP team will actively monitor and evaluate whether the conditions of this IEE are being implemented effectively and whether there are new or unforeseen consequences arising during implementation that were not identified and reviewed in this IEE. If new or unforeseen consequences arise during implementation, the team will suspend the activity and initiate appropriate, further review in accordance with 22 CFR 216. USAID Monitoring shall include regular site visits.

7. New or modified activities. As part of its Work Plan, and all Annual Work Plans thereafter, IPs, in collaboration with their C/AOTR, shall review all on-going and planned activities to determine if they are within the scope of this IEE.

If any IP adds new activities or makes substantial modifications to existing activities, an amendment to this IEE addressing these activities shall be prepared for USAID review and approval. No such new activities shall be undertaken prior to formal approval of this amendment.

Any ongoing activities found to be outside the scope of the approved Regulation 216 environmental documentation shall be halted until an amendment to the documentation is submitted and written approval is received from USAID.

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8. Compliance with Host Country Requirements. Nothing in this IEE substitutes for or supersedes IP, subgrantee and subcontractor responsibility for compliance with all applicable host country laws and regulations. The IP, subgrantees and subcontractor must comply with host country environmental regulations unless otherwise directed in writing by USAID. However, in case of conflict between hostUSAID regulations, the latter shall govern.

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