Attachment J.2. Approved Initial Environmental Examinations.pdf

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COVER SHEET

INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ACTIVITY DATA:

Program/Activity Number: --- Program Activity Title: USAID/DRC Health Office Portfolio Country/Region: DRC/East Africa

Functional Objective: Investing in People Program Elements: HIV/AIDS, TB, malaria, MCH, FP/RH, nutrition, and WASH

Period Covered: 2014-2019 LOP Amount $780 million

IEE Prepared By: USAID Health Team IEE Amendment (Y/N): No Submitted By: Izetta Minko-Moreau, Health Office Director Current Date 21 July, 2015 Expiration Date 31 July, 2020

Other Relevant Environmental Compliance Documentation: 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.” See also WHO’s “Safe Management of Wastes from Healthcare Activities.”

ENVIRONMENTAL ACTION RECOMMENDED

Categorical Exclusion X Negative Determination X

Positive Determination X Deferral X

ADDITIONAL ELEMENTS:

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

*22 CFR 216.3 (b)(1) applies

SUMMARY OF FINDINGS:

Scope. This IEE addresses all activities anticipated under the USAID/DRC Health Office portfolio, which cuts across DO1: Selected National-Level Institutions More Effectively Implement Their Mandates, DO2:

Lives Improved through Coordinated Development Approaches in Select Regions, and TO3: Foundation for Durable Peace Strengthened in Eastern DRC. It applies to all health activities implemented under DRC’s 2015-2019 CDCS. It replaces and supercedes the Mission’s previous IEEs; except that ongoing activities operating under an approved environmental mitigation and monitoring plan (EMMP) may continue operating under that EMMP.

mailto:USAID http://www.usaidgems.org/Sectors/healthcareWaste.htm

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USAID/DRC is one of the Agency’s largest health portfolios and as such, is a focus country for the following U.S. government and international global initiatives: President’s Emergency Plan for AIDS Relief (PEPFAR), President’s Malaria Initiative (PMI), and Ending Preventable Child and Maternal Deaths

(EPCMD).

Recommended Determinations. The following table summarizes the recommended determinations for the Health Office portfolio, per the intervention categories established by this IEE for purposes of environmental review. For each, a link is provided to the 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)

Link to full analysis

1. Studies, Surveys/Public Health Surveillance & other Data-Gathering Assessments, Models, & Capacity-Building In Support of All Areas Above.

Dissemination Of Resulting Information/Lessons Learned/Best Practices

X X Click here

2. Healthcare Provider Training; Healthcare Workforce Strengthening and Development X X Click here

3. Direct and Capacity Building Support for Health Service Delivery and Access to Health Services, excluding Commodity Procurement/Supply Chain Strengthening

X X Click here

4. Procurement, storage, management, distribution, and disposal of medical and pharmaceutical commodities

X X Click here

5. Social and Behavior Change Communication X Click here

6. Small-Scale Water Supply & Sanitation X X Click here

7. Construction other than Water/Sanitation Infrastructure X X Click here

8. Technical support to indoor residual spraying (IRS) X X Click here

9. Policy and Strategy Development 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: (1) Implementing Partner 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.

Section 4 also specifically restricts the procurement, use or support of pesticides to 3 activities: LLIN procurement and distribution and IRS technical support. Specific restrictions are attached in each case.

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OTHER RELEVANT ENVIRONMENTAL COMPLIANCE DOCUMENTATION:

Integrated Vector Management Programs for Malaria Vector Control (2012 Update).

http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/39185.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/39185.pdf

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NOTE: Acronym List attached as Annex 1.

PROGRAM/ ACTlVITY DATA:

Program/Activity Number: 612-008

Program Activity Title: USAID/DRC Health Office Portfolio

Country/Region: Democratic Republic of Congo/Africa

Functional Objective: Investing In People

Program Area: 3.1—Health

Program Elements: 3.1.1—HIV/AIDS

3.1.2—Tuberculosis

3.1.3—Malaria

3.1.5—Other Public Health Threats

3.1.6—Maternal and Child Health (MCH)

3.1.7—Family Planning and Reproductive Health (FP/RH)

3.1.8—Water Supply and Sanitation

3.1.9—Nutrition

1.0 Background and Program Description

1.1 PURPOSE AND SCOPE OF IEE

This IEE addresses the entire portfolio of activities under the USAID/DRC Health Office portfolio, applying to all health sector activities implemented under DRC’s 2015-2019 CDCS. It replaces and supersedes the Mission’s 2009-2015 Health Sector IEE except that ongoing activities operating an approved environmental mitigation and monitoring plan (EMMP) may continue operating under that EMMP.

Any new or substantially modified activities, even under continuing projects, must comply fully with this IEE. (See section 4 for EMMP requirements.)

For purposes of analysis, this IEE synthesizes current and anticipated health portfolio activities1 into a set of 9 intervention categories, each of which contains a number of entailed activities. 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, attendant conditions, for these activities.

In addition, this IEE sets out project-level2 implementation procedures intended to assure that conditions in this IEE are translated into activity-specific mitigation measures, and to assure systematic compliance

1 NOTE: 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; e.g. the ‘Food and Nutrition Technical Assistance (FANTA III) Project.’

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 mechanism.”) 2 See footnote 1.

IEE: Supply Chain Management System Agreement pg. 6 Date with this IEE during activity and project implementation. These procedures are themselves a general condition of approval for the IEE, and their implementation is therefore mandatory.

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)

DRC faces a growing burden of disease and critical shortage of healthcare resources, similar to most countries in sub-Saharan Africa. The epidemiological profile is characterized by a high prevalence of communicable diseases including malaria, tuberculosis and HIV/AIDS; high incidence of maternal and child health problems; an increasing burden of non-communicable diseases, and the resurgence of the neglected tropical diseases. Although there has been a significant decline in infant and under-five mortality, the rates are still high.

USAID/DRC’s health sector activities are a response to these human and development needs and are in line with the identified priorities of the Government of DRC (GDRC) for the health sector, as laid out in GDRC’s 2010-2015 National Health Development Plan (PNDS).

1.3 DRC HEALTH PORTFOLIO: OVERVIEW

Health issues (sub-sectors) targeted. The USAID/DRC health portfolio incorporates interventions in seven sub-sectors, listed immediately below. The general focus and content of interventions in each sub-sector are then described.

1. HIV/AIDS

2. Malaria

3. Tuberculosis

4. Maternal Neonatal and Child Health (MNCH)

5. Family Planning and Reproductive Health (FP/RH)

6. Water Supply and Sanitation (WASH)

7. Nutrition

These sub-sectors correspond directly to foreign assistance framework program elements, as listed in the heading information on page one.

Integrated Programming Approach. Across these subsectors, the USAID/DRC Health Office has been working towards an integrated programming approach, as:

(a) The health needs being addressed are highly inter-related, e.g. success in child health requires improving nutrition, malaria control, access to clean water, and improved sanitation highly;

(b) The same health facilities, health care workers, and community-based networks and organizations deliver care and services across multiple sub-sectors.

Thus, while sub-sectors are discussed individually below, individual projects in many instances carry out activities in more than one sub-sector, and the projects are designed to be mutually supportive and synergistic so that the portfolio overall embodies an integrated approach.

HIV/AIDS: A key objective of USAID/DRC’s HIV/AIDS related support will be to help the DRC better integrate Global Fund, PEPFAR, and other donor resources into a coherent countrywide program, with a

IEE: Supply Chain Management System Agreement pg. 7 Date particular focus on preventing mother to child transmission. HIV/AIDS initiatives will further focus on increasing access to Anti-Retroviral Therapies (ARTs), and improving the coordination and integration of health care and treatment services across HIV/AIDs, Malaria, TB, Maternal, Neonatal, and Child Health

(MNCH).

Malaria: The Presidential Malaria Initiative (PMI) supports the National Malaria Control Program (NMCP) in implementing DRC’s malaria prevention, treatment, and research programming. Specifically, through September 2014, PMI support within DRC reached 181 health zones, covering nearly 33 million individuals. PMI efforts are comprised of: dissemination of, and awareness raising and behavior change communication (BCC) on, long-lasting insecticide treated nets (LLINs); prevention of malaria in pregnancy through BCC, procurement and use of sulfadoxin-pyrimethamine (SP), and health worker training among other efforts; improving management of malaria cases and pharmaceutical systems to improve efficiency and effectiveness of treatment efforts; bolstering monitoring and evaluation of PMI efforts; and strengthening, capacity building, and integration of health services in DRC.

At the time this IEE is being prepared, PMI activities are not currently planned to include Indoor Residual Spraying (IRS). However, IRS is considered a part of DRC’s NMCP, and PMI support may be directed toward IRS activities within the life of this IEE.

Tuberculosis (TB): USAID will focus efforts on strengthening national, regional, and district capacity to:

effectively manage pharmaceutical commodities related to treatment of TB and MDR-TB and deliver services related to TB treatment, prevention and immunization, and care.

TB-related programming will also involve supporting DRC Ministry of Health (MOH) with provision of adequate equipment at health zone, DPS, and facilities through Global Development Alliance (GDA) partnerships. USAID will support DRC’s National TB Program (NTP).

Maternal, Neonatal, and Child Health: Both maternal and under-five, infant, and neonatal mortality rates in DRC are among the highest in the world, with malaria, diarrhea, and pneumonia accounting for over 50 percent child deaths, and neonatal causes contributing an additional 21 percent of under-five deaths.

MNCH interventions will focus on improving access and quality along the continuum of care for pregnant women and children to ANC, labor and delivery services, postnatal care, and preventative and curative child health services, setting up community-oriented case management services with focus on malaria, pneumonia, and diarrhea, and improving immunization and nutrition services.

Family Planning/Reproductive Health (FP/RH): The DRC has one of the lowest contraceptive prevalence rate’s (CPRs) in the world, at lower than 8%. With a weak policy environment and limited knowledge, awareness, and/or prioritization among the population USAID efforts continue to focus on advocacy for prioritization and implementation of FP/RH programs. USAID support will include procurement and distribution of contraceptive products and strategic guidance to the national FP agenda within DRC, through participation on the Family Planning Technical Committee and Contraceptive Security Working Group. USAID intervention will also include fistula repair and treatment services.

WASH: USAID/DRC WASH programming will focus on community-led total sanitation (CLTS) and participatory hygiene and sanitation transformation. These objectives will utilize a combination of community-oriented BCC and training and awareness raising, introduction of new technologies and commodities (e.g. point-of-use water purification), and infrastructure development such as borehole drilling, installation of tap stands, and support to communities in construction of their own latrines (e.g.

pit). It may also be included to a lesser extent in the IHP activity but in a limited number 8 of 79 health zones covered.

Nutrition: DRC ranks as the hungriest country in the world based on the International Food Policy Research Institute’s 2011 Global Hunger Report. In balancing available resources and the severity of

IEE: Supply Chain Management System Agreement pg. 8 Date malnutrition in the DRC, USAID efforts will prioritize promotion of breastfeeding, including counseling services from professionals and peers. Additionally, micronutrient supplements such as iron and folic acid for pregnant women and vitamin A for children – will be provided. Food for Peace (FFP) currently provides ready-to-use-therapeutic-foods (RUTF) for the DRC, including in areas supported by the health programs. FFP will manage the purchase, transport, and storage of these RUTF.

USAID/DRC’s nutrition programming is being conducted in alignment with the National Nutrition Program and in coordination with donors such as the European Community Humanitarian Office, UNICEF, and the World Food Program.

1.4 INTERVENTION CATEGORIES FOR PURPOSES ENVIRONMENTAL REVIEW

Many types of interventions will be undertaken in more than one—and sometimes several—of the health subsectors described above. For example, procurement of pharmaceuticals will be supported in the Malaria, HIV/AIDS, MCH, and TB areas, all of which also include training of care providers and strengthening health care commodity supply chains.

The potential adverse environmental and health impacts of concern for pharmaceutical procurement, care provider training, etc. are similar across these health subsectors. Analyzing these impacts separately for each sub-sector would be highly redundant, and make for an inefficient and unmanageably long IEE.

For the purposes of environmental review and compliance, interventions in the USAID/DRC health portfolio are therefore consolidated into the following intervention categories.

1. Studies, Surveys/Public Health Surveillance & other data-gathering assessments, models, & capacity-building in support of all areas above. Dissemination of Resulting Information/Lessons Learned/Best Practices

2. Healthcare Provider Training; Healthcare Workforce Strengthening and Development

3. Direct and Capacity Building Support for Health Service Delivery and Access to Health Services, excluding Commodity Procurement/Supply Chain Strengthening

4. Procurement, storage, management, distribution, and disposal of medical and pharmaceutical commodities

5. Social and Behavior Change Communication

6. Small-Scale Water Supply & Sanitation

7. Small-Scale Construction other than Water/Infrastructure

8. Technical Support for IRS Programming

9. Policy and Strategy Development

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. Annex II of this document provides a mapping of the anticipated Health Office Portfolio against these intervention categories. This Annex should be reviewed and updated to align with modifications to the health office portfolio on a rolling basis throughout the life of this IEE.

2.0 Environmental Baseline, Context and Regulations

2.1 ENVIRONMENTAL BASELINE

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Geography & Climate. DRC is located northeast of Angola in Central Africa. It is the 2nd largest country in Sub-Saharan Africa and the 11th largest country in the world at 2.34 million km2, of which almost 78,000 km2 is water. DRC has 37 km of coastline on the Atlantic Ocean. The center of the country has a vast low-lying plateau while mountains are located in the east. The Atlantic Ocean is the lowest point in the country and the highest point is Pic Marguerite on Mont Ngaliema (Mount Stanley) at 5,110 m. DRC has a hot and humid climate in the equatorial river basin, but a cooler, drier climate in the southern highlands. The eastern highlands are cooler and wetter. North of the equator, the wet season is April to October and the dry season is December to February. The wet and dry season are reversed south of the Equator.3

Ecological Zones & Biodiversity. DRC has 14 ecoregions either entirely or partly within its borders: (1) Central African Mangroves, (2) Atlantic Equatorial coastal forests, (3) Western Congolian forest-savanna mosaic, (4) Angolan Miombo woodlands, (5) Southern Congolian forest-savanna Mosaic, (6) Central Congolian lowland forests, (7) Eastern Congolian swamp forests, (8) Western Congolian swamp forests, (9) Northeastern Congolian lowland forests, (10) Northern Congolian forest-savanna mosaic, (11) East Sudanian savanna, (12) Ruwenzori-Virunga montane moorlands, (12) Albertine Rift montane forests, and (14) Central Zambezian Miombo woodlands. 4The Congo Basin, which stretches from the DRC across the Central African Republic, Congo, Cameroon, Equatorial Guinea and

Gabon at 500 million acres, is one of the most critical wilderness areas on Earth, and the second largest tropical forest. It is home to 10,000 species of tropical plants, 30% of which are unique to the region.

Four-hundred mammal species, including endangered forest elephants, chimpanzees, bonobos, and lowland and mountain gorillas, are found in the basin, as well as 1,000 species of birds and 700 species of fish.

The leading cause of wildlife loss in the Congo Basin is the commercial bushmeat trade. Monkeys and antelope are the main targets but gorillas and bonobos are also at risk. Over a million tons of bushmeat is consumed in the DRC every year, and in rural areas, bushmeat can be the primary income source for families, and the only export that can earn a profit. In addition, the international demand for ivory continues to drive the killing of protected elephants, threatening to eliminate them entirely. The World Wildlife Fund works to fight illegal trade, mainly through TRAFFIC, the largest global wildlife trade monitoring network.5

DRC has five natural UNESCO World Heritage Sites: Garamba National Park, Kahuzi-Biega National Park, Okapi Wildlife Reserve, Salonga National Park and Virunga National Park. Virunga National Park, located in the center of the Albertine Rift in the Great Rift Valley, is especially unique, as it contains a range of biodiversity and habitats unparalleled in Africa. The Rwenzori and Virunga Mountains are home to the

3 https://www.cia.gov/library/publications/the-world-factbook/geos/cg.html 4 http://www.eoearth.org/view/article/151683/ 5 http://www.worldwildlife.org/places/congo-basin

Source: CIA World Factbook https://www.cia.gov/library/publications/the-world-factbook/geos/cg.html http://www.eoearth.org/view/article/151683/ http://www.worldwildlife.org/places/congo-basin

IEE: Supply Chain Management System Agreement pg. 10 Date two most active volcanoes in Africa, and endemic, rare and globally threatened species like the mountain gorilla are found here. 6 Established in 1925, Virunga National Park is also the oldest National Park in Africa.

Soils. There are two main types of soils in DRC. The equatorial soils are found in the warm lowlands of the central basin and receive plenty of rain throughout the year. They are covered by dense forests and are very thick in swampy areas and nourished by humus. The savannah soils face a greater threat of erosion, but the river valleys still contain rich and fertile alluvial soils. In the most productive agricultural area, the highlands of the Great Lakes region, the soils are rich and derived from volcanic lava. 7

Water Resources. DRC is the most water-rich country in Africa with 52% of the continent’s surface water reserves and 23% of its internal renewable water resources. In addition, rain is abundant and DRC receives 6,000 billion m3 of rainfall every year. Seventy percent of DRC’s renewable water resources are generated from internal rainfall. The Congo River has the largest discharge volume in Africa and the 62% of the Congo Basin lies within DRC, covering 98% of the country. Water resources are linked to the country’s vast forest ecosystems, and even though surface water is abundant, the majority of the population depends on groundwater and springs for safe drinking water. Groundwater comprises 47% of DRC’s internal renewable water resources. An estimated 1,000 deep-drilled wells exist in the DRC, servicing only a small percentage of the population. Limited well drilling has occurred since the 1990’s, and most groundwater is exploited using dug wells or mechanical pump wells.

Despite the fact that DRC is “water-rich”, it is currently facing a serious drinking water supply crisis.

Water infrastructure was plagued by years of underinvestment, conflict, and a fast growing population, and only around 26% of the population has access to safe drinking water. Additional issues in the water sector include degradation of drinking water sources from land-use changes, poor construction and maintenance of rural water systems, water pollution, and poor governance. However, since 2004, water governance is improving as the government has committed to water sector reform, which is also the focus of much international assistance. 8

Effects of Conflict. DRC has faced endless conflict over control of its natural resources, as well as civil war for the past two decades, largely funded by DRC’s mineral abundance. Tantalum, tungsten, tin and gold are all found abundantly within DRC, and are required for the majority of popular electronic devices. In addition to the atrocities inflicted on innocent people for leverage in the mines, DRC’s ecosystems have also faced the burden of ongoing conflict. Both Congolese refugees and rebels take shelter in the forests, mining, clearing forest tracts, and hunting bushmeat to subside. In addition, war had led to a prioritization of resources that has destabilized national park management. Wildlife and their habitats are vulnerable to miners and harvesting by poachers, and new roads lead to mining sites in forests that were previously impenetrable, leading to environmental destruction from hunters, loggers and miners.9

Climate Change. Climate change poses an additional threat to the ecosystems and people of the DRC, who have already been challenged by years of conflict, poverty, and environmental degradation. Almost 90% of the population depends on rain-fed agriculture. Rising temperatures are expected to cause an increase in crop diseases, such as cassava mosaic virus, and droughts that will disrupt both food and cash crops. Climate simulations also predict floods, landslides and soil erosion, especially in the Congo Basin. Malaria and water-borne diseases are expected to become more widespread and water stress will become more acute, leading to indirect effects on DRC’s energy supply, which is mostly derived from

6 http://whc.unesco.org/en/list/63 7 http://www.britannica.com/EBchecked/topic/132363/Democratic-Republic-of-the-Congo-DRC#toc40788 8 http://postconflict.unep.ch/publications/UNEP_DRC_water.pdf

9 http://janegoodall.ca/get-involved/conflict-drc-threatening-biodiversity/ http://whc.unesco.org/en/list/63 http://www.britannica.com/EBchecked/topic/132363/Democratic-Republic-of-the-Congo-DRC%23toc40788 http://postconflict.unep.ch/publications/UNEP_DRC_water.pdf http://janegoodall.ca/get-involved/conflict-drc-threatening-biodiversity/

IEE: Supply Chain Management System Agreement pg. 11 Date hydroelectric power. Mangroves are especially vulnerable due to their unique biodiversity, and have already seen degradation by coastal erosion in the mangrove Marine Park in Moanda.

DRC’s government ratified the United Nations Framework Convention on Climate Change (UNFCCC) in 1994, and presented its Initial National Communication (INC) in 2002, in which they listed national producers of greenhouse gases and estimated the country’s vulnerability to climate change and suggested policy approaches to adaptation and mitigation. A National Adaptation Programme of Action was produced in 2006. Civil Society Organizations (CSOs) have been involved in REDD+ (Reducing Emissions from Deforestation and Forest Degradation in Development Countries) projects, such as personnel training, sharing knowledge regionally, REDD+ pilot projects and launching the first university curriculum on REDD+. 1011 DRC’s forests hold the largest carbon stocks on any African country, so preservation is essential to fighting climate change. 12

2.2 DEVELOPMENT CONTEXT

Overview of Health Sector The majority of Congolese live in extreme poverty and lack access to healthcare. Years of conflict have left hospitals and health centers poorly staffed and equipped. Less than a quarter of the population can access proper sanitation facilities and less than half the population can access clean water. As a result, water-borne diseases, like cholera, are common. However, malaria is a greater threat, as two out of every five deaths among children is caused by malaria. In addition, malnutrition is widespread, and war and disease have left an estimated four million orphans, many of whom end up begging on the streets of Kinshasa. 13 HIV/AIDS is also an issue. In 2013, the number of people living with HIV was 440,000, and 1.1% of adults aged 15 to 49 were affected. In addition, the number of orphans aged 0-17 due to AIDS was 350,000.14

Preventable childhood death and maternal mortality in DRC pose a serious challenge to the health sector. With 1% of the global population, DRC is responsible for over 6% of global under-five mortality.

Only 31% of children under 1 year old are completely vaccinated and almost half of children under five are chronically malnourished. In addition, a 2007 survey revealed that maternal mortality rates to be 549 deaths for every 100,000 births. Nineteen percent of women between the ages of 15 and 49 die due to maternal complications.15

The Ministry of Health (MOH) is restructuring to streamline functions and increase access to quality services, but the national supply chain management system is extremely weak. For this reason, USAID is focusing on improving the management capacity of provincial and local institutions, including financial resource planning, budgeting and accounting, human resource management, drug procurement, and the application of health data and information technology. USAID is also working to change behaviors by communicating best practices in the areas of sanitation, family planning, bed net use, and the prevention of HIV/AIDS. USAID/DRC contributes towards the Global Health Initiative with investments in the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI).16

10 http://www.un-redd.org/UNREDDProgramme/CountryActions/DemocraticRepublicofCongo/tabid/1027/language/en- US/Default.aspx 11 http://r4d.dfid.gov.uk/PDF/Outputs/MediaBroad/02-Democratic-Republic-of-Congo-Talks-Climate.pdf 12 http://www.friendsofthecongo.org/images/pdf/CongoRainforest_latest.pdf 13 http://www.our-africa.org/democratic-republic-of-congo/poverty-healthcare 14 http://www.unaids.org/en/regionscountries/countries/democraticrepublicofthecongo 15 http://www.easterncongo.org/mnch 16 U.S. Agency for International Development, Democratic Republic of the Congo, Country Development Cooperation Strategy 2015-2019 http://www.un-redd.org/UNREDDProgramme/CountryActions/DemocraticRepublicofCongo/tabid/1027/language/en-US/Default.aspx http://www.un-redd.org/UNREDDProgramme/CountryActions/DemocraticRepublicofCongo/tabid/1027/language/en-US/Default.aspx http://www.un-redd.org/UNREDDProgramme/CountryActions/DemocraticRepublicofCongo/tabid/1027/language/en-US/Default.aspx http://r4d.dfid.gov.uk/PDF/Outputs/MediaBroad/02-Democratic-Republic-of-Congo-Talks-Climate.pdf http://www.friendsofthecongo.org/images/pdf/CongoRainforest_latest.pdf http://www.our-africa.org/democratic-republic-of-congo/poverty-healthcare http://www.unaids.org/en/regionscountries/countries/democraticrepublicofthecongo http://www.easterncongo.org/mnch

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Eastern DRC Conflict Eastern DRC has been an active conflict zone on and off since 1996. The Peace, Security and Cooperation Framework for DRC, signed in Addis Ababa in 2013 is a promising sign that peace prospects are more likely, but many previous peace agreements have been implemented with no fulfillment, and the conflict continues. The Government of DRC negotiated a ceasefire with M23 in 2013 and retook control of the Goma capital, but more than 40 other armed groups still operate in the region. Transitioning to a stable democracy will be a challenge in a country where political processes are often considered untrustworthy, non-inclusive, and lacking leadership. For example, despite women’s activism, women’s attendance at peace negotiations has been inadequate, and they have essentially no role in decision making.

There are many factors driving the ongoing conflict and instability in eastern DRC. Competition over natural resources, such as timber, diamonds, and petroleum, is a major cause, and also severely affects the quality of the environment. Traditional ethnic hostilities are manipulated by local and regional politicians for their own advantage, and are exacerbated by an influx of small arms into the area.

Further, lack of economic opportunity attracts youth to armed forces and local militias that have become criminal gangs. USAID efforts aim to provide practical solutions to specific drivers of conflict, initiate interventions to establish or solidify peace, and the provision of humanitarian and protective services. Additional support, such as implementing a political agreement for peace and achieving demonstrable security sector reform, will need to be coordinated with the USG and other external parties.17

2.3 ENVIRONMENTAL LAWS AND REGULATIONS

The Constitution. Environmental law in DRC starts with the Constitution of the Third Republic, adopted on February 18, 2006. Article 53 states that every person has a right to a healthy environment, that the environment must be protected, and that the state is responsible for protecting the environment and the health of the people. Further, Article 123 makes provisions for laws to be made concerning the protection of the environment and tourism and Article 203 calls for cooperative governance between central and provincial administration to protect and conserve the environment, natural sites and landscapes.18

EIA & Law No. 11/009. In 2003, a Mining Regulation that followed DRC’s Mining Code of 2002, required mining exploration and development projects to complete an EIA and public consultations. Approved in 2011, Law No. 11/009, the Basic Fundamental Principles Relating to Environmental Protection, extended the regulatory framework beyond the mining sector by requiring that developers of industrial, commercial, agricultural, forestry, mining and telecommunications projects complete an Environmental and Social Impact Assessment (ESIA) and undertake public consultation. It also requires environmental audits; environmental evaluation of policies, plans and programs; the creation of new institutional structures; and an Environmental Fund for research, conservation, clean-up operations, rehabilitation and pollution prevention. However, this law does not provide guidance on types of projects subject to an ESIA, or details on development and validation of the ESIA. 19 The management of EIAs is the responsibility of the Ministry of Environment, Nature Conservation and Tourism (MENCT), but matters

17 U.S. Agency for International Development, Democratic Republic of the Congo, Country Development Cooperation Strategy 2015-2019 18 http://www.saiea.com/dbsa_book/ 19http://www.iaia.org/conferences/iaia13/proceedings/Final%20papers%20review%20process%2013/Environmental %20and%20Social%20Impact%20Assessment%20in%20Countries%20with%20Limited%20Regulatory%20Frame works%20- %20Lessons%20from%20the%20Democratic%20Republic%20of%20the%20Congo%20.pdf?AspxAutoDetectCook ieSupport=1 http://www.saiea.com/dbsa_book/ http://www.iaia.org/conferences/iaia13/proceedings/Final%20papers%20review%20process%2013/Environmental%20and%20Social%20Impact%20Assessment%20in%20Countries%20with%20Limited%20Regulatory%20Frameworks%20-%20Lessons%20from%20the%20Democratic%20Republic%20of%20the%20Congo%20.pdf?AspxAutoDetectCookieSupport=1 http://www.iaia.org/conferences/iaia13/proceedings/Final%20papers%20review%20process%2013/Environmental%20and%20Social%20Impact%20Assessment%20in%20Countries%20with%20Limited%20Regulatory%20Frameworks%20-%20Lessons%20from%20the%20Democratic%20Republic%20of%20the%20Congo%20.pdf?AspxAutoDetectCookieSupport=1 http://www.iaia.org/conferences/iaia13/proceedings/Final%20papers%20review%20process%2013/Environmental%20and%20Social%20Impact%20Assessment%20in%20Countries%20with%20Limited%20Regulatory%20Frameworks%20-%20Lessons%20from%20the%20Democratic%20Republic%20of%20the%20Congo%20.pdf?AspxAutoDetectCookieSupport=1 http://www.iaia.org/conferences/iaia13/proceedings/Final%20papers%20review%20process%2013/Environmental%20and%20Social%20Impact%20Assessment%20in%20Countries%20with%20Limited%20Regulatory%20Frameworks%20-%20Lessons%20from%20the%20Democratic%20Republic%20of%20the%20Congo%20.pdf?AspxAutoDetectCookieSupport=1 http://www.iaia.org/conferences/iaia13/proceedings/Final%20papers%20review%20process%2013/Environmental%20and%20Social%20Impact%20Assessment%20in%20Countries%20with%20Limited%20Regulatory%20Frameworks%20-%20Lessons%20from%20the%20Democratic%20Republic%20of%20the%20Congo%20.pdf?AspxAutoDetectCookieSupport=1

IEE: Supply Chain Management System Agreement pg. 13 Date related to mining are under the responsibility of the Director of Protection of the Mining Environment

(DPEM).2021

Chapters 5 and 6 of Law No. 11/009 are related to management and conservation of natural resources and the prevention of risks and control of pollution and other nuisances. Chapter five holds the state responsible for the conservation and sustainable management of ecosystems, natural resources, and monuments, and specifically addresses preventing the degradation of land, soil and vegetation, as well as surface and groundwater. It also addresses the sustainable management of biodiversity and forests and prohibits activities that will negatively affect the environment in forbidden zones or protected areas.

Section 1 of chapter six addresses commercial industries, and requires a permit (either by the national or provincial government) in cases where activities will pose dangers for health, security or the environment, and requires that measures are put in place to avoid accidents or pollution that will have negative consequences for the environment or health. Section 2 addresses air, water, soil, odor, and noise pollution, and also mentions the use of pesticides, fertilizers and other techniques to ensure a sustainable productivity of the soil. The remaining sections address the management of chemical products, waste, genetically modified organisms, and natural catastrophes. 22

International Conventions. DRC is party to the international conventions including the following:

Ramsar (1994) for the protection of important wetlands, CITES (1975) for the conservation of threatened wildlife and plants, Convention on Biological Diversity (1992), World Heritage Convention (1975), and the African Convention on nature and natural resource conservation (1976). 23

3.0 Potential Environmental Impacts & Recommended

Determinations, Including Conditions As set out in section 1.4, for the purpose of environmental review, current and anticipated activities in the USAID/DRC Health Office portfolio are grouped into the following intervention categories.

1. Studies, surveys/public health surveillance and other data-gathering assessments, models, and capacity-building in support of all areas above. Dissemination of resulting information/lessons learned/best practices.

2. Healthcare worker/delivery agent training; Healthcare workforce training, strengthening, and development.

3. Direct and management capacity-building support for health service delivery and access to health services, excluding commodity procurement/supply chain strengthening.

4. Procurement, storage, management, distribution and disposal of public health commodities & equipment; strengthening public health commodity supply chain management.

5. Social and behavior change communication (BCC), except for WASH.

6. Water supply and sanitation.

7. Rehabilitation and construction other than water/sanitation infrastructure.

8. Technical assistance to Indoor Residual Spraying (IRS).

20 http://www.srk.com/files/File/South-Africa/publicDocuments/Mongbwalu/EIS_en/2%20- %20Supporting%20Documentation/Appendix%20A_Governance%20framework.pdf 21 http://www.saiea.com/dbsa_handbook_update2012/pdf/chapter05.pdf 22 http://www.leganet.cd/Legislation/Droit%20administratif/Environnement/JOS.16.07.2011.pdf 23 Review of the Legal Framework for Mining & Conservation in the DRC, WWF DRC, 11 October 2011 http://www.srk.com/files/File/South-Africa/publicDocuments/Mongbwalu/EIS_en/2%20-%20Supporting%20Documentation/Appendix%20A_Governance%20framework.pdf http://www.srk.com/files/File/South-Africa/publicDocuments/Mongbwalu/EIS_en/2%20-%20Supporting%20Documentation/Appendix%20A_Governance%20framework.pdf http://www.saiea.com/dbsa_handbook_update2012/pdf/chapter05.pdf http://www.leganet.cd/Legislation/Droit%20administratif/Environnement/JOS.16.07.2011.pdf

IEE: Supply Chain Management System Agreement pg. 14 Date

9. Policy & strategy development

Each category contains a number of entailed activities. In this section, the entailed activities are described and their potential impacts analyzed. On this basis, Recommended Determinations are made.

In many cases, Negative Determinations entail conditions. Upon approval of this IEE, implementation of these conditions becomes mandatory.

3.1 ADVERSE IMPACTS OF HEALTH CARE SERVICE DELIVERY DUE TO FAILURE TO

PROPERLY MANAGE RESULTING WASTES

This section is a general discussion and analysis of waste-related impacts of health care activities. It is referenced at several points in the analyses of the specific intervention categories that follow in sections 3.2—3.10. 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.

• 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 & Medical Supplies, Including Condoms. Pharmaceutical drugs including vaccines have specific storage time and temperature requirements, and may expire or lose efficacy before they are able to be 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 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 results in release of toxic pollutants into the air. Inefficient and insecure sorting and disposal may allow drugs beyond their expiry

IEE: Supply Chain Management System Agreement pg. 15 Date date to be diverted for resale to the general public. Incinerators are not planned in any activity at this time.

Potentially infectious wastes. However, 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 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.

3.2 STUDIES, SURVEYS/PUBLIC HEALTH SURVEILLANCE AND OTHER DATA-GATHERING

ASSESSMENTS, MODELS, AND CAPACITY-BUILDING IN SUPPORT OF ALL AREAS ABOVE.

DISSEMINATION OF RESULTING INFORMATION/LESSONS LEARNED/BEST PRACTICES.

Activities in this category are intended to provide information and analysis necessary to target health interventions, to assess their effectiveness, and to improve intervention methods by the larger set of public health actors in DRC. Activities in this intervention category may include but are not limited to:

• Epidemiological surveillance and reporting for multiple diseases and conditions including but not limited to malaria, HIV/AIDS, malnutrition, tuberculosis (TB)*, serious childhood diseases

• Sanitary surveys

• Water quality monitoring

• Entomological (disease vector) surveys/monitoring, including but not limited to support to a national laboratory for monitoring insecticide resistance.

• Health care facility surveys

• Gaps and needs assessments in access to care and health care management systems

• Opinion/behavior surveys

*In the case of TB, USAID support will support TB surveillance/case identification and diagnosis by: (1) scaling up decentralized case management of MDR TB, including building laboratory capacity and procurement of Gene Xpert machines and Xpert MTB/RIF diagnosis cartridges (covered under section 3.5), and by training laboratory staff, including in implementation of WHO-compliant biosafety regimes for handling MDR and extensively drug-resistant (XDR) samples; and (2) improving community sputum collection and transportation of samples, by: (a) Supporting community health workers and volunteers with supplies for sputum collection and supplies; and (b) Supporting health center and district health management teams to improve systems to transport specimen samples for TB as well as for other diseases (e.g. HIV) from health center to district hospital; and from district hospital to central hospital.

IEE: Supply Chain Management System Agreement pg. 16 Date

Note: this intervention category does NOT include human drug trials or experimental human-subject studies, which are not covered by this IEE. It does NOT include procurement of equipment or supplies, which is covered by section 3.5. It does NOT include construction or refurbishment of facilities, which is covered by section 3.8.

Analysis of Potential Adverse Impacts & Considerations Regarding Recommended Determinations

No significant adverse impacts, whether direct or indirect are foreseeable from this intervention category---except for activities involving the collection and/or analysis of blood or body fluid samples or other activities that may generate medical waste. This includes, e.g. tuberculosis surveillance, which involves collection and transportation of sputum samples.

*No research involving human subjects is anticipated. Specifically, this IEE does not provide approval for research activities requiring human subjects; research and studies conducted under this IEE are anticipated and understood to involve extensive interviewing to elicit information or understand experiences.

Research activities involving the use of human subjects would have other attendant considerations and implementation conditions. As such, should any such research activities develop under the Health Office portfolio, appropriate environmental evaluation will have to be conducted prior to their intervention once the nature of the research activity is understand. Please refer to the table below for the specific conditions at this time.

Recommended Determinations

Activity/Class of activities

Recommended Determination

22 CFR 216 Reference or Condition

IEE: Supply Chain Management System Agreement pg. 17 Date

Studies, surveys/public health surveillance & other data-gathering assessments, models, & capacity-building in support of all areas above that DO NOT involve the collection, handling, and/or analysis of blood or body fluid samples.

Dissemination of resulting information/lessons learned/best practices.

Categorical Exclusion

22 CFR 216.2 (c)(2)(xiv) Studies, projects, or programs intended to develop the capability of recipient countries to engage in development planning.

Studies, surveys/public health surveillance & other data-gathering assessments, models, & capacity-building in support of all areas above that DO involve the collection, handling, and/or analysis of blood or body fluid samples.

Negative

Epidemiological surveillance supported with…