Attachment_1_-_Initial_Environmental_Examination_IEE.pdf

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 1

INITIAL ENVIRONMENTAL EXAMINATION

APPROVAL DOCUMENT

PROGRAM/ACTIVITY DATA:

Program/Activity Number: Health Systems Strengthening Program Activity Title: USAID/Mozambique Integrated Health Office Portfolio Strengthened Systems to Deliver Health, Nutrition, and Social Services Country/Region: Mozambique

Functional Objective: Investing in People Program Area: 3.1 Health Program Elements: A047, A048, A049, A052, A053, A0142 (HIV/AIDS, TB, Malaria, MCH, FP and Nutrition)

Period Covered: 2014‐2019 LOP Amount approximately $556 million

IEE Prepared By: Josh Habib & Patrick Hall, GEMS Team, The Cadmus Group, Inc.

Josh.Habib@cadmusgroup.com IEE Amendment (Y/N): No Submitted By: Eugene Cooper, Health Systems Strengthening Division Chief Current Date October 2014 Expiration Date 30 September 2019

Other Relevant Environmental Compliance Documentation: USAID/Mozambique Integrated Health Office Portfolio IEEs for 2014‐2019: Increased Coverage of High‐Impact Health and Nutrition Services and Increased Adoption of Positive Health and Nutrition Behaviors.

ENVIRONMENTAL ACTION RECOMMENDED

Categorical Exclusion X Negative Determination X

Positive Determination Deferral X

ADDITIONAL ELEMENTS:

EMMP: | Conditions: X | PVO/NGO: | Pesticides:*

*22 CFR 216.3 (b)(1) applies

SUMMARY OF FINDINGS:

Scope. This IEE addresses the entire portfolio of activities anticipated under IR 4.3: Strengthened Systems to Deliver Health, Nutrition, and Social Services of the USAID/Mozambique Health Status of Targeted Population Groups Improved (D04) portfolio. It applies to all health systems strengthening (HSS) activities implemented under Mozambique’s 2014‐2018 CDCS and Project Appraisal Document (PAD). It replaces and supersedes the Mission’s previous IEEs; except that ongoing activities operating

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 2 an approved environmental mitigation and monitoring plan (EMMP) may continue operating under that

EMMP.

NOTE: The activities within HSS do not include the following activities expected to be conducted in conjunction with HSS activities: behavior change for improved health activities; direct delivery of health care services; nor any small‐scale installation, construction, or repair/rehabilitation of water supply, or sanitation systems or devices such as boreholes, wells, latrines, etc. As such, the potential environmental impacts and/or risks entailed by these activities are not covered within this IEE. Instead, these activities are addressed in the IEEs prepared for USAID/Mozambique’s DO 4, IR 4.1: Increased Coverage of High‐Impact Health and Nutrition Services and DO 4, IR 4.2: Increased Adoption of Positive Health and Nutrition Behaviors respectively.

Recommended Determinations. The following table summarizes the recommended determinations for the health portfolio, per the intervention categories established by this IEE for purposes of environmental review. For each, a link is provided to the entailed activity descriptions, analysis of potential environmental impacts, and activity‐by‐activity determinations and conditions within section 3 of the IEE.

Intervention Category Categorical Exclusion(s)

Negative Determination(s)

Positive Determination(s)

Deferral of Threshold Decision

Link to full analysis

Financial Management, Strategic Planning, and Budget Execution of Key Health Service Functions

X X

Click here

Logistics Management and Supply Chain of Health‐Related Commodities to Ensure Availability at Local Levels

X X

Click here

Civil Society Engagement in the Health Sector

X X Click here

Generation, Dissemination, and Use of Health Data for More Effective Decision‐Making

X X X Click here

Rehabilitation and Small‐Scale Construction of warehouses and health facilities

X X Click here

General Implementation & Monitoring Conditions. In addition to the specific conditions enumerated in Section 3, 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 require, in summary: (1) IP Briefings on Environmental Compliance Responsibilities; (2) Development of environmental mitigation and monitoring plans (EMMPs); (3) Integration and implementation of EMMPs in workplans and budgets; (4) Integration of compliance responsibilities in prime and sub‐contracts and grant agreements; (5) Assurance of sub‐grantee and sub‐contractor capacity and compliance; (6) Health Team environmental compliance monitoring; (7) 22 CFR 216 documentation coverage for new or modified activities; and (8) compliance with host country requirements.

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 4

INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ACTIVITY DATA:

Program/Activity Number: Health Systems Strengthening

(Activity Number not applicable at this level)

Program Activity Title: USAID/Mozambique Integrated Health Office Portfolio Strengthened Systems to Deliver Health, Nutrition, and Social Services

Country/Region: Mozambique/ Africa

Functional Objective: Investing in People Program Area: 3.1 Health Program Elements: A047, A048, A049, A052, A053, A0142 (HIV/AIDS, TB, Malaria, MCH, FP and Nutrition)

1.0 BACKGROUND AND PROGRAM DESCRIPTION

1.1 PURPOSE AND SCOPE OF IEE

This IEE addresses the entire portfolio of activities anticipated under the USAID/Mozambique Health Systems Strengthening (HSS) portfolio. The HSS portfolio is defined by Intermediate Result (IR) 4.3 in support of the mission’s Development Objective 4 (D04), “Health status of targeted population groups improved” and includes all activities implemented under the “USAID/Mozambique 2014‐2018 Health Systems Strengthening Project Appraisal Document” (PAD). The HSS portfolio of activities will operate in parallel with IR 4.1: Increased Coverage of High‐Impact Health and Nutrition Services and IR 4.2:

Increased Adoption of Positive Health and Nutrition Behaviors.

This IEE, together with IEEs being developed for IR 4.1 and IR 4.2, replaces and supersedes the Mission’s “Improving the Health of Mozambicans” Health Sector IEE (FY 2009‐2014); except that ongoing activities operating an approved environmental mitigation and monitoring plan (EMMP) may continue operating under that EMMP.

As with all IEEs, and in accordance with 22 CFR 216, this IEE reviews the reasonably foreseeable effects of subject activities on the environment. On this basis, this IEE recommends Categorical Exclusions or Threshold Decisions for these activities. Upon approval of this IEE, these recommendations become affirmed Categorical Exclusions and Threshold Decisions, and implementation of recommended conditions becomes mandatory.

In addition, this IEE sets out project1‐level implementation procedures intended to assure that conditions in this IEE are translated into activity‐specific mitigation measures, and to assure systematic compliance with this IEE during project and program implementation. These procedures are themselves a general condition of approval for the IEE, and their implementation is therefore mandatory.

1 The terms “activity” and ‘project” are used throughout this IEE per their standard meaning in environmental impact assessment, and NOT as per USAID’s new programming framework. As such, a project is a cluster of activities executed under a single, thematically focused prime contract or award. By contrast, in USAID’s new programming framework, “project” describes a sector‐ or sub‐sector portfolio, covering multiple contracts or awards, and “activity” denotes a single such contract or award (“implementation vehicle.”)

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 5

This IEE is a critical element of a mandatory environmental review and compliance process meant to achieve environmentally sound activity design and implementation.

1.2 PROGRAM BACKGROUND: CONTEXT & JUSTIFICATION

The main public health system challenges in Mozambique include inadequate infrastructure and funding for health facilities and supplies, a shortage of health workers, an overreliance on donors for health financing, deficient information systems, and a weak civil society that does not hold the Government of the Republic of Mozambique (GRM) accountable for health service provision. E.g:

per 100,000 people there are only 6.5 doctors, 28 nurses, and a total of 66 health care workers, a proportion that is among the lowest in the world.

access to medicines is limited by poorly functioning warehouses and a weak medical supply chain.

high child and maternal mortality rate reflect the difficulty women and children have in accessing essential health services.2

Mozambique is one of the countries selected as a Global Health Initiative (GHI) country under President Obama’s six‐year, US$63 billion health initiative. Under GHI, the U.S. and Mozambique will work to reduce maternal, newborn, and child mortality in rural populations by: strengthening governance in the health sector; improving retention and management of the health workforce; and expanding access and uptake of quality maternal, newborn, and child health services.

USAID/Mozambique HSS activities respond to these human and development needs, with a goal of strengthening systems to deliver health, nutrition, and social services. To achieve this goal, HSS portfolio activities will enhance the health system to improve financial planning and management, improve data collection and utilization, strengthen supply chain management and civil society engagement in health policy, and enhance warehouse and health facility infrastructure. See Section 1.4 for a list of illustrative implementing mechanisms for USAID/Mozambique HSS activities.

1.3 INTERVENTION CATEGORIES FOR PURPOSES OF ENVIRONMENTAL REVIEW

The USAID/Mozambique HSS portfolio incorporates strategic planning, financial, logistics, engagement, and information collection activities. For the purposes of environmental review , this IEE groups and assesses USAID/Mozambique HSS portfolio interventions according to the following five categories.

1. Financial Management, Strategic Planning, and Budget Execution of Key Health Service Functions (sub‐IR 4.3.1)

2. Logistics Management and Supply Chain of Health‐Related Commodities to Ensure Availability at Local Levels (sub‐IR 4.3.2)

3. Civil Society Engagement in the Health Sector (sub‐IR 4.3.3)

4. Generation, Dissemination, and Use of Health Data for More Effective Decision‐Making (sub‐IR

4.3.4)

5. Rehabilitation and Small‐Scale Construction of Warehouses and Health Facilities

Each intervention category has a number of entailed activities; these are set out, and, where not self‐ explanatory, annotated in Section 3 of this IEE. As noted, the first four categories correspond to the four HSS sub‐IRs. The fifth intervention category has been added to address construction activities.

2 USAID/Mozambique Health Systems Strengthening PAD, 25 July 2014.

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 6

1.4 IMPLEMENTING MECHANISMS FOR USAID/MOZAMBIQUE HSS ACTIVITIES

HSS Illustrative Implementing Mechanisms

Implementing Mechanisms for Sub‐IR 4.3.1: Improved Financial

Management, Strategic Planning, and Budget Execution of Key Functions

Activity Total Budget

FY2014‐2018

Instrument IPR

Award Start

Date

Award End

Date

Health and Social Welfare

Systems Strengthening

(FORSSAS)*

$20,000,000

Cooperative

Agreement No Jul‐12 Jul‐16

Columbia University

(Strengthening ISCISA's

Health Management Course)

$1,300,000 Cooperative

Agreement No Jan‐14 Jan‐17

Donor to Donor Agreement with DANIDA (Danish

International Development

Agency) in Tete Province

$ 4,000,000

Bi‐partite donor‐ to‐donor agreement

Yes Mar‐14 Dec‐17

Direct Agreement with Sofala

Province $ 3,000,000

FAR PIL (with potential to transition to a cost‐type agreement PIL after 1 year)

Yes

TBD

(anticipated

8/2014)

1 year FARA followed by cost‐type reimbursem ent for the life of the project)

Direct Agreement with

Manica Province $ 2,000,000

Cost‐type reimbursement Yes TBD

TBD (4

years)

Costing TA for the Strategic

Plan for the Health Sector

(PESS)

$ 500,000 Field support buy in No TBD TBD

Direct Agreement with the

National Institute of Health

(INS)

$ 1,000,000

Initial FAR PIL

(with potential in the future to transition to a cost‐type reimbursement

PIL)

Yes

TBD

(anticipated

2/2014)

TBD

Support to APE (Community

Health Worker/Agente

Polivalente Elementar) program

$ 4,500,000

Direct agreement with

DNSP paired with traditional implementing mechanism

Yes TBD TBD

*The FORSSAS agreement is in the process of work plan revision and budget realignment, maintaining the same budget ceiling, however, with a reduction in the period of performance by one year.

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 7

Implementing Mechanisms for Sub IR 4.3.2: Improved Logistics Management of

Commodities to Ensure Availability at Local Levels

Activity Total Budget

FY2014‐2018

Instrument IPR

Award Start

Date

Award End

Date

Systems for Improved

Access to

Pharmaceuticals and

Services (SIAPS)

$ 1,200,000

Buy in to global cooperative agreement

No Sep‐11 Sep‐16

Promoting the Quality of

Medicines (PQM) $ 900,000

Buy in to global cooperative agreement

No Sep‐09 Sep‐14

Direct Agreement with

Central Medical Stores (

CMAM)

$ 4,000,000

FAR PIL (with potential to transition to a cost‐type agreement PIL after 1 year)

Yes Dec‐13 Dec‐14

Construction Oversight $ 4,200,000 Contract Yes Apr‐14 Apr‐17

Supply Chain and Logistics

System Strengthening

Technical Assistance*

$ 60,000,000

Contract

(Washington‐ based IQC)

No

TBD

(anticipated

1/2015)

TBD (5 year award)

Procurement of Essential

Commodities* $ 400,000,000

Contract

(Washington‐ based IQC)

No

TBD

(anticipated

1/2015)

TBD (5 year award)

Warehouses $ 7,500,000 Contract No

TBD

(anticipated

10/2014)

TBD

* Currently, procurement of essential commodities and supply chain and logistics system strengthening is mainly provided through two contracts: Supply Chain Management Systems (SCMS) and DELIVER. These mechanisms will end in September 2015; thus, there is a need to transition to new mechanisms within the project period. These are anticipated to begin late in CY 2014; at that time, the Mission plans to transition support to PQM and SIAPS into the new mechanism.

Implementing Mechanisms for Sub‐IR 4.3.3: Strengthened Civil Society Engagement in the

Health Sector

Activity Total Budget

FY2014‐2018

Instrument IPR

Award Start

Date

Award End

Date

Capable Partners Program

(CAP) – sub‐grants and organizational development for local organizations**

$ 4,000,000 Cooperative

Agreement Potential Jul‐09 Jul‐16

N’weti (Youth‐friendly

RH/FP/HIV services and health sector governance)

$ 4,000,000 Cooperative

Agreement Yes Jun‐13 Jun‐17

Foundation for Community

Development (FDC) $ 3,000,000

Cooperative

Agreement Yes Nov‐13 Nov‐16

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 8

Reencontro $ 1,300,000 FOG Yes Oct‐13 Oct‐16

Mozambique National

Nursing Association

(ANEMO)

$ 2,300,000 Cooperative

Agreement Yes Oct‐13 Oct‐16

Local Capacity Development

IQC (Capacity building providers for APS grantees)

$ 1,500,000 IQC Yes TBD TBD (5 year award)

Cross‐cutting Mechanisms which include IR 4.3

Activity Total Budget

FY2014‐2018

Instrument IPR

Award Start

Date

Award End

Date

Strategic Information Project

(M‐SIP) ‐ JSI DQA

$ 3,600,000

Cooperative

Agreement No Aug‐13 Aug‐16

Strategic Information

Program ‐ Jembi Health

Systems

$ 900,000 Cooperative

Agreement No Oct‐13 Oct‐16

SI Fellowship Strategic

Information APS grantees $ 1,600,000 FOG Yes TBD

TBD (3 year award)

Demographic and Health

Survey $ 3,500,000

Contract (field support buy in) No

TBD (for 2016

DHS)

TBD

Census 2017 $ 1,500,000 TBD TBD

TBD

(anticipated

2016 for 2017 census)

TBD

Evaluations $ 6,250,000 MMEMS and other Potential TBD TBD

2.0 COUNTRY AND ENVIRONMENTAL BASELINE INFORMATION

2.1 MOZAMBIQUE ENVIRONMENTAL PROFILE

Geography. Mozambique is located in Southeastern Africa along the Indian Ocean. It is separated from Madagascar by the Mozambique Channel and is bordered to the north by Tanzania, to the west by Zambia, Malawi, and Zimbabwe, and to the South by Swaziland and South Africa. Total land area is almost 800,000 km2, with 2,470 km of coastline.3 Generally, the country is low lying, with coastal plains covering about 42% of land, mainly in the south and along the coast. Twenty‐nine percent of the country is covered with plateaus, while 25% is highlands ranging from 500 to 1000 meters in the north and west.

Around 25 rivers flow through Mozambique, exiting in the Indian Ocean. The Zambezi River is the largest, and cuts across central Mozambique. 4

3 CIA World Factbook, Mozambique 4 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on September 18 at: http://pdf.usaid.gov/pdf_docs/PNAEA332.pdf

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 9

Climate. Mozambique’s climate is semi‐arid and subtropical in the south and tropical in the north. There is a warm, wet season from November to March and a dry, cooler season from April to October. Climate is influenced by altitude, latitude, and proximity to the sea. Mozambique receives from about 300 to 2,000 millimeters of rain per year, depending on location. The lowlands in the southern interior typically receive less rain than the Zambezi Delta and the Mountainous areas in the north and west. Droughts and floods are common as precipitation varies significantly from year to year.

Ecosystems. The main terrestrial ecosystem in Mozambique is the Miombo woodlands, dry tropical woodlands consisting of broad‐leaved trees. Mozambique also has 13,400 km2 of coastal forest located from the northern border to the Zambezi river. The Mopane woodlands, dominated by the Mopane tree, are located in Western Mozambique in the Zambezi Valley and in the southwestern Gaza Province. In the dry southern areas of Mozambique where tree canopy cover is less than 20%, ecosystems consist of savanna grassland and thorn scrub vegetation. In western Mozambique and the northern Tete Province, the montane ecosystems include evergreen forests and afroalpine grasslands, shrublands and moorlands at the highest elevations.

The main freshwater and wetland ecosystems in Mozambique are rivers and their riparian zones, deltas, natural lakes and artificial lakes created by dams. Lake Niassa and the Zambezi Delta are important examples. Lake Niassa is the southernmost Rift Valley Lake and is famous for its endemism, mainly the cichlid fish. The Zambezi delta was nominated as a Ramsar site, and supports a large population of aquatic birds, heron and ducks. It is also an important breeding ground for the wattled crane, and a temporary home to thousands of migratory species that depend on the habitat. Certain species in the delta habitats are also endangered, threatened, or of important commercial value. Some of the largest and most important lakes for biodiversity, fisheries and tourism include Lake Bilene, Nhambavale, Quissico, Inharrime, and Piti. These lakes are important feeding and breeding grounds, but are threatened by unregulated development, pollution and tourism.

Coastal and marine ecosystems occupy 572,000 km2 of Mozambique’s total area and consist of dunes, beaches, seagrass beds, coral reefs, and mangroves. The dunes between Bazaruto Island and Ponta do Ouro are considered the tallest vegetated dunes in the world; the flora is diverse and the area contains many medicinal plants for local communities. Sandy beaches are home to five species of endangered marine turtles, as well as ghost crabs and coastal birds. These ecosystems are also under stress from unregulated development, tourism, and deforestation. Thirteen species of seagrass beds have been identified, and are important as a nursery and feeding area for sea turtles, dugongs, and other commercially valuable species. Coral reefs are located along the northern coast, mainly fringing reefs with hard corals and rich biodiversity. About 300 species of hard corals and 50 species of soft corals have

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 10 been identified. Small‐scale fisheries depend on these reefs and associated ecosystems, as well as a growing tourism industry in the south, where Scuba diving is popular. Nine different species of mangrove trees have been identified in Mozambique. Mangrove forests are located on sheltered areas of the coast, mainly the estuaries and deltas of the Zambezi, Púnguè, and Save Rivers, and are important for local community use and ecosystem services, such as coastal protection. 5

Soils. Granite rock underlies most of northern and west‐central Mozambique, while the soils of southern and east‐central Mozambique are sedimentary. The northern and central regions have more fertile, water‐retentive soils with a higher content of red clay. In the south, soils are mostly sandy and infertile;

fertile soils are limited to alluvials in the valleys of the Save, Limpopo, Incomáti, Umbelúzi, and Maputo rivers. 6

Water Resources. Mozambique has abundant water resources due to its major river systems which also offer hydroelectric and irrigation potential. The Rovuma River lines Mozambique’s northern border with Tanzania while the Zambezi River and its tributaries are found in the central region. The Zembezi has 819 km in Mozambique and drains more than 225,000 km2 of the central region. The southern border with Swaziland and South Africa is formed partly by the Maputo River. Other drainage areas include the Messalo, Púngoè, Revuè, Buzi and Limpopo rivers. Mozambique shares several lake borders with Malawi (Nyasa, Chiuta and Chilwa) but has no other important lakes besides those created by the hydroelectric dam network. 7

Mozambique has considerable groundwater potential with well yields in the Zambezi and Incomati basins at 70,000 m3 per day. Seventeen km3 of groundwater is produced annually and 97.3 km3 of surface water. Including some overlap between ground and surface water, total renewable water sources equal around 100.3 km3 per year. The Cahora Bassa dam on the Zambezi River is the largest hydroelectric plant in southern Africa with an installed capacity of 2,060 MW. Surface water is the main water source in Mozambique, although groundwater is used for drinking water supply in certain urban areas. In rural areas, shallow wells and handpump‐mounted boreholes are the main source of drinking water.

The greatest source of water withdrawal is agriculture, where irrigation withdrew 86.6% in 2000, mainly from surface water, the main source of water in Mozambique. In 2003, 1,181 km2 was irrigated. Total irrigation potential is around 3,300,000 ha, where the main areas suitable for irrigation are the center and the north of the country. The Zambezia province is home to 60% of the irrigation potential. Most irrigated lands are occupied by smallholder farmers and agricultural enterprises. Small‐scale irrigation schemes exist all over the country, but are mostly abandoned or in bad condition due to the civil war, lack of inputs and technical assistance, and floods in 2000 and 2001. 8

Biodiversity & Protected Areas. Mozambique is home to 5,500 plants, 581 birds, and 205 mammals.

About 250 of these species are endemic to Mozambique. Five species of sea turtles occur along the coast, and eighteen other species of marine animals including dolphins, whales, seals, and dugong.

Around 300 species of plants are on the “Red List” of threatened and endangered species, 55 of which

5 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on September 18 at: http://pdf.usaid.gov/pdf_docs/PNAEA332.pdf 6 Mozambique, Accessed via the internet on 19 September at:

http://www.britannica.com/EBchecked/topic/395363/Mozambique#toc43964 7 Mozambique, Accessed via the internet on 19 September at:

http://www.britannica.com/EBchecked/topic/395363/Mozambique#toc43964 8 Mozambique, accessed via the internet on 19 September at:

http://www.fao.org/nr/water/aquastat/countries_regions/moz/index.stm

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 11 are endemic to Mozambique. In addition, 105 mammal species are of conservation concern. The white renoceros, tsesebe, sitatunga, black rhinoceros, giraffe, roan antelope, mountain reedbuck, and cheetah are the most threatened large mammal species. The Gorongosa Mountains, Great Inselberg Arcihpelago of Quirimbas and the Chimanimani Mountains are all sites of high importance for biodiversity. 910

Mozambique has extended its protected areas from 11% to 25% of its national area, and has added new conservation areas as well, such as Quirimbas National Park for marine and coastal ecosystems and Limpopo Transfrontier National Park. Several areas are also under special protection, including Marromeu Complex, Maputoland Centre of Endemism, and the Chimanimani and Namuli Mountains. 11 Overall, protected areas include six national parks, eight national reserves, 13 forest reserves, two integral reserves, and 14 hunting concession designated for sport hunting and protecting species. In addition, the Marromeu Natural Reserve and Lake Niassa Partial Reserve are Ramsar sites due to the extensive biodiversity of their wetlands. 12Mozambique has one UNESCO Cultural World Heritage Site, the Island of Mozambique. 13

2.2 HEALTH AND HEALTH SECTOR PROFILE

Mozambique has made advances towards reaching its health‐related Millennium Development Goals, but access to basic services remains low. Neonatal mortality decreased to 30 deaths/1000 and under‐ give morality to 90 deaths/1000. However, in other areas health outcomes are still substandard. Malaria causes 26% of hospital deaths, HIV prevalence is still high, the national TB response is complicated by multi drug TB resistance (Mozambique is among the 22 high‐burden TB countries), and women and children have inadequate access to health services. In addition, recurrent natural disasters and epidemics exacerbate health system issues and require stronger surveillance systems and accordance with international health regulations. 14

In 2013, the number of people living with HIV in Mozambique was 1.6 million. Adults have a 10.8% prevalence rate, while 190,000 children aged 0 to 14 are living with HIV. In 2013, around 82,000 people died from AIDS.15 Only 40% of HIV+ pregnant women received Anti‐Retroviral Therapy (ART) for their own health, while 86% received ART for Prevention of Mother‐to‐Child Transmission. 16 From 2004 to 2009, the number of children receiving ART increased from 500 to 12,647, representing 27% of children eligible for and requiring treatment.17

9 Mozambique-Country Profile, accessed via the internet on 18 September at:

http://www.cbd.int/countries/profile/default.shtml?country=mz#status 10 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on September 18 at: http://pdf.usaid.gov/pdf_docs/PNAEA332.pdf 11 Mozambique-Country Profile, accessed via the internet on 18 September at:

http://www.cbd.int/countries/profile/default.shtml?country=mz#status 12 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on September 18 at: http://pdf.usaid.gov/pdf_docs/PNAEA332.pdf 13 Mozambique- Properties inscribed on the World Heritage List, accessed via the internet on September 18 at:

http://whc.unesco.org/en/statesparties/MZ/ 14 Mozambique Country Cooperation Strategy at a Glance, accessed via the internet on 22 September 2014 at:

http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_moz_en.pdf 15 Mozambique HIV and AIDS estimates (2013), accessed via the internet on 22 September 2014 at:

http://www.unaids.org/en/regionscountries/countries/mozambique/ 16 http://www.unaids.org/en/regionscountries/countries/mozambique/ 17 Mozambique Maternal, Newborn & Child Survival, accessed via the internet on 22 September 2014 at:

http://www.countdown2015mnch.org/documents/2014Report/Mozambique_Country_Profile_2014.pdf

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 12

The high child and maternal mortality rate is a reflection on the difficulty women and children have in accessing essential health services. The main causes of death for children under five are neonatal death (34%), Malaria (18%), “other” (16%), and Sepsis (Tetanus, Meningitis, Encephalitis‐ 7%). The main causes of maternal death are indirect (29%), hemorrhage (25%) and hypertension (16%). In 2011, only 54% of live births were attended by skilled health personnel. Disease prevention and treatment in children is another challenge. Around 56% of children under five with diarrhea received treatment in 2011, while less than 40% of children slept under insecticide‐treated nets. Nutrition is also a major issue among children, as 43% have stunted growth, and 16% are moderately or severely underweight. 18

National water supply coverage in Mozambique was 47% in 2008, 77% in urban areas and 29% in rural areas. Sanitation coverage was 17%, with major differences again among urban (38%) and rural (4%) areas. Urban water and sanitation infrastructure will face increasing challenges as urban population growth increases at a rate or 4% each year. Mozambique’s water vulnerability is represented by its reliance on upstream neighbors for 50% of surface water. Further, climate change has implications for both food and water security as analysis suggests that Mozambique will face warming in inland regions and sea level rise along the coast. The government recognizes the role water and sanitation plays in reducing poverty levels, and has addressed water, sanitation and hygiene issues in its Five Year Plan (2010‐2015), Poverty Reduction Action Plan, and UN Development Assistance Framework. 19

2.3 ENVIRONMENTAL INSTITUTIONS, POLICY AND REGULATION

Environmental regulations in Mozambique begin with the Constitution of 2004, which addresses the environment and quality of life, and states “the state and local authorities, in collaboration with out appropriate partners, to adopt policies for the protection of the environment and care for the rational utilization of all natural resources”. It also claims that the state shall adopt policies to prevent and control pollution and erosion, integrate environmental objectives into sector policies, promote the integration of environmental values in educational policies and programs, and ensure the rational and sustainable utilization of natural resources.

In Mozambique, the Ministry of Environmental Coordination (MICOA) is responsible for implementing the National Environmental Management Program (NEMP) and associated environmental legislation, and for coordinating with other ministries to integrate environmental aspects into their projects and policies. The NEMP was formulated by MICOA in 1996 and contained an Environmental Policy, a proposal for the Framework Environmental Act (passed in 1997) and an Environmental Strategy. MICOA has established regulations relating to environmental management including for industrial activities, mining, standards for environmental quality and effluent emissions, and environmental auditing. MICOA is also responsible for regulating Environmental Impact Assessments (EIAs) which involves approving the terms of reference, reviewing completed EIAs and implementing an audit process.

The Environmental Law of 1997 is the basis of all legislation regarding preservation of the environment.

The law’s objective is to define the legal basis for judicious utilization and management of the environment, aiming to achieve sustainable development in Mozambique. The law’s mandate includes public and private activities that have any risk of influencing the environment. The principles set out by this law are rational and sustainable management and use of the environment for the maintenance of biodiversity and ecosystems and improvement of quality of life for citizens; recognition of traditions and

18 Mozambique Maternal, Newborn & Child Survival, accessed via the internet on 22 September 2014 at:

http://www.countdown2015mnch.org/documents/2014Report/Mozambique_Country_Profile_2014.pdf 19 Mozambique WASH Sector Brief, accessed via the internet on 22 September 2014 at:

http://www.ircwash.org/sites/default/files/ISF-2011-Mozambique.pdf

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 13 local knowledge which may contribute to the conservation and preservation of natural resources;

precaution for activities that might harm the environment; an integrated, global vision of the environment; public participation; equitable access to natural resources by all; and commitment to minimizing trans‐boundary impacts. Chapter four of this law, Prevention of Environmental Damage, requires licensing of activities likely to cause environmental impacts. Issuance of a license depends on an EIA being completed and accepted by MICOA.

Mozambique has several laws that provide the legal framework for ownership and management of environmental resources, such as forests, land, and water. Mozambique’s Forestry and Wildlife Policy, Law, and Regulations confirm the State’s mandate over natural forests and wildlife resources, calls for establishing protected areas to conserve biodiversity, and provides guidelines for the sustainable use of these resources. The Forestry and Wild Law regulations include licensing details and information about exploitation, game farms, and fines. The Land Act provides the legal framework for land and natural resource ownership in Mozambique. It establishes that surface and groundwater belong to the state and people of Mozambique, and requires a license for use of large quantities of water. It also recognizes the need to create protected areas for ecologically sensitive land and natural resources. The Water Law in Mozambique established the state’s ownership of inland surface and groundwater and requires a license for the use of large quantities of water for industry, irrigation or other purposes. Licenses are granted if the water use does not cause significant environmental damages. These laws acknowledge the rights of local communities over land and natural resources, and encourage their involvement in management and conservation. 20,21

Mozambique is a member of the World Bank and IUCN, and therefore should follow these organization’s guidelines related to biodiversity conservation. In addition, Mozambique is party to multiple international conventions and protocols to protect the environment, including the convention on the International Trade in Endangered Species of Wild Flora and Fauna (CITES), the Vienna and Montreal Conventions for protection of the Ozone, the Kyoto Protocol, the UN Convention on Biological Diversity, the Cartagena Protocol on Biosafety, the Convention on Persistent Organic Pollutants (POPs), the UN Framework Convention on Climate Change, and the Bamako Convention on the Ban of the Import into Africa and the Control of Transboundary Movements of Hazardous Wastes within Africa. 22

2.4 REGULATIONS RELEVANT TO THE HEALTHCARE SECTOR

Mozambique’s Regulation for the Prevention of Pollution and Marine and Coastal Environmental establishes the legal basis for protection and conservation of seas, lakes, rivers, beaches and fragile ecosystems, and limits pollution resulting from discharge by ships, platforms, or land‐based sources along the coast. It also prohibits the discharge of toxic or harmful wastewater or substances that may cause pollution.

In 2006 Mozambique passed the Regulation on Waste Management to encourage waste producers to minimize waste. It establishes rules related to production and discharge of toxic and polluting substances as well as activities that degrade the environment.

The Regulation regarding Standards for Environmental Quality and the Discharge of Effluent defines standards for environmental quality and effluent emission for receiving bodies of water, treatment

20 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on

21 Mozambique, accessed via the internet on 22 September at: http://www.saiea.com/saiea-book/mozam1.pdf 22 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 14 technologies, systems and methods. It requires that liquid industrial effluent by discharged through an appropriate entity in accordance with emission and discharge standards, and that the point of discharge is determined during the environmental licensing process so the water quality of the receiving body will be unchanged.

The Regulation regarding the Quality of Water for Human Consumption establishes water quality parameters for human consumption, and procedures for controlling water quality to protect human health. 23

As set out in section 1.3, for the purpose of environmental review, current and anticipated activities in the USAID/Mozambique HSS portfolio are grouped into five intervention categories, of which the first four correspond to HSS sub‐IRs:

1. Financial Management, Strategic Planning, and Budget Execution of Key Health Service Functions (sub‐IR 4.3.1)

2. Logistics Management and Supply Chain of Health‐Related Commodities to Ensure Availability at Local Levels (sub‐IR 4.3.2)

3. Civil Society Engagement in the Health Sector (sub‐IR 4.3.3)

4. Generation, Dissemination, and Use of Health Data for More Effective Decision‐Making (sub‐IR

4.3.4)

5. Rehabilitation and Small‐Scale Construction of Warehouses and Health Facilities

Following section 3,1 below, each intervention category is addressed in turn, in section 3.2‐3.6. These sections begin by enumerating the constituent activities in each intervention category, assess their potential adverse impacts, and on that basis put forward recommended determinations, including conditions.

This section is a general discussion and analysis of waste‐related impacts of health care activities, including those associated with HSS interventions. It is referenced at several points in the analyses of the specific intervention categories that follow in sections 3.2—3.6. It supports this subsequent analysis; no recommended determinations are attached specifically to this section.

Although healthcare activities provide many important benefits to communities, they can also unintentionally do harm via poor management of the wastes they generate. These wastes generally fall 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.

23 http://www.erm.com/PageFiles/13352/Draft-EIA-Aug2013/Chapter-2-LNG.pdf

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Hazardous healthcare wastes 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 wastes, 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.

Pharmaceutical Wastes and Medical Supplies, including condoms: 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 has 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, which 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.

Potentially infectious wastes: 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.

These agents can enter the body through punctures and other breaks in the skin, mucous membranes in the mouth, by being inhaled into the lungs, being swallowed, or being transmitted by a vector organism.

Those who come in direct contact with the waste are at greatest risk. Examples include healthcare workers, cleaning staff, patients, visitors, waste collectors, disposal site staff, waste pickers, substance abusers and those who knowingly or unknowingly use “recycled” contaminated syringes and needles.

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

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 16 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.

Constituent Activities. This intervention category consists of activities to:

1. Support planning and financing strategies at national and local levels

1a. Support health care financing, resource allocation, investment, and expenditure management through training of other capacity building efforts

1b. Support the Ministry of Health (MOH) to develop a health sector financing strategy

2. Increase public financial management capacity

2a. Support strategic plan execution and build financial management skills within the provinces and districts

3. Strengthen governmental management capacity, including leadership development for regional and local entities

3b. Support GRM on strengthening health‐related strategies, including training of other capacity building efforts

4. Develop co‐financing mechanisms with governmental and private organizations

Potential Adverse Impacts & Considerations Regarding Recommended Determinations. All activities in this intervention category are intended to improve financial management capacity and strategic planning for health care systems. This intervention category includes technical assistance and trainings, capacity building, and enhanced partnerships. Certain of these activities do present a level of risk related to the increased production of medical waste as discussed in Section 3.1. As health systems are strengthened and financial and strategic planning enhanced, the healthcare infrastructure will be better equipped to provide increased levels of patient care, including improved access to clinical services and a wider selection of readily available pharmaceutical products and other medical supplies. Unless parallel measures to strengthen health care waste management are implemented, the delivery of these services and consumption of health‐related products will increase health care waste streams that in many cases already exceed current management capacity.

Recommended Determinations. Following from the analysis above, the following determination is recommended for activities in this category.

Activity/ Determination 22 CFR 216 Reference or Condition

1. Support planning and financing strategies at national and local level

1a. Support health care financing, resource allocation, investment, and expenditure mgmt.

1b. Support the Ministry of Health (MOH) to develop a health sector financing strategy

Negative Determination with Conditions

Financial planning, resource allocation and other forms of strategy and management support in the sector at all levels must integrate the need for and, wherever appropriate, make provision for the costs of facilities and processes to appropriately manage medical waste.

Note: It is understood that the USAID support to health delivery and management systems and organizations, including those typified by HSS interventions, does not, in most cases, equate to direct USAID control over these systems and organizations.

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg. 17

2. Increase public financial management capacity

2a. Support strategic plan execution and build financial management skills within the provinces and districts

3. Strengthening governmental management capacity, including leadership development for regional and local entities

3b. Support to Government of the Republic of Mozambique (GRM) on strengthening health‐related strategies

4. Develop co‐financing mechanisms with governmental and private organizations

However, IPs must proactively advance these principles in their analysis, recommendations, and technical support.

Mandatory reference: The USAID Sector Environmental Guidelines for Healthcare Waste (http://www.usaidgems.org/Sectors/healthcareWaste.htm) contains guidance, which must inform compliance with these conditions, particularly in the section titled, “Minimum elements of a complete waste management program.” Other important references to consult in establishing a waste management program are “WHO’s Safe Management of Wastes from Healthcare Activities.”

Constituent Activities. This intervention category consists of activities to:

1. Strengthen strategic planning and management capacity within the pharmaceutical logistics sector

2. Improve public‐sector medical supplies/commodity procurement, including disposal of expired/unused commodities

2a. Develop and implement a supplier and purchaser performance monitoring system

3. Support public sector warehousing and distribution of commodities at all levels

3a. Assess storage infrastructure and support to provincial health and district authorities to develop and implement infrastructure improvement plans

4. Strengthen supply chains

4a. Improve use of medicines and enhance pharmaceutical services

Potential Adverse Impacts & Considerations Regarding Recommended Determinations. Activities in this intervention category are intended to improve the logistics and supply chain management of medical commodities. This intervention category includes strategic planning, capacity building, and supply procurement and warehousing. These activities are intended to increase the quantity, quality and affordability of medical commodities available to support health care delivery.

Procured commodities end up as waste after use (e.g., condoms, LLINs, laboratory chemicals, test kits), generate waste as a consequence of their use (e.g., injectable pharmaceuticals) or have the potential to become due to spoilage or expiration (e.g., all pharmaceuticals). Improper disposal of potentially infectious and pharmaceutical wastes has potentially significant adverse impacts, as discussed in Section

3.1. Activities that increase commodity supply and availability will increase existing impacts, unless they incorporate parallel efforts to strengthen end‐of‐life commodity management.

The extent of USAID control of the in‐country supply chain and use of these commodities can range from complete to partial, depending on the programming context. To the greatest degree practicably

USAID/ Mozambique Health Systems Strengthening (DO4: IR 4.3) portfolio IEE Oct 2014 pg.