J.15__Initial_Environment_Examination_(IEE).pdf

INITIAL ENVIRONMENTAL EXAMINATION

& REQUEST FOR CATEGORICAL EXCLUSION

PROGRAM/ACTIVITY DATA:

Country/Region: Benin/West Africa

Program/Activity Title: Benin Health Program (BHP)

IEE Prepared By: Benjamin Opoku, Regional Environmental Compliance Advisor and

MEO USAID/WA

Current Date: July 6, 2015

IEE Amendment (Y/N): No, this new IEE completely supersedes the previous FHP IEE (originally approved 2012-10-02) IEE Expiry Date: September 30, 2020

Funding Begin: o/a July 15, 2015 Program End: September 30, 2020

IEE Expiry Date: December 31, 2020

Life of Project Amount: $$118,500,000.00 LOP

ENVIRONMENTAL ACTION RECOMMENDED:

Categorical Exclusion: X Negative Determination: X

Positive Determination: _ X __ Deferral: _____

ADDITIONAL ELEMENTS:

CONDITIONS: X EMMP: X IRS SEA: _X_ Water Quality Assurance Plan (WQAP): __X__

Other Relevant Environmental Compliance Documentation:

Supplemental Environmental Assessment (SEA) for Presidential Malaria Initiative I n d o o r Residual Spraying (IRS) for Malaria Control in Benin. (Benin IRS SEA)). All activities relating to IRS are covered under the SEA. The current SEA developed and approved in 2011 is in force until the end of 2015. A revised SEA will be needed in 2016. (see p. 25 below).

SUMMARY OF FINDINGS

Purpose and Scope of the IEE

This IEE provides the initial review of all planned activities to be implemented under the Benin Health Program BHP. In accordance with 22CFR216, this IEE provides the first review of all planned activities with respect to environmental impact potential and recommended threshold determinations.

Intervention Category Categorical exclusion

Neg w/cond Positive Det.

Technical assistance and training in support of private and public health sector service delivery and access to health services

X X

Social marketing, education and social behavior change communication, SBCC

X X

Support for laboratory testing and implementation of quality control measures for anti-malaria medications at local and national levels

X

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

X

Indoor residual spraying

LLITN

X

IRS SEA

Water supply and sanitation (including infrastructure)

WQAP

General Implementation & Monitoring Conditions

In addition to the recommended threshold determinations enumerated in Section 3.0 of this IEE, general monitoring and implementation requirements are specified in Section 4.0 of the IEE. These require:

a) Implementing Partner briefings on environmental compliance responsibilities;

b) Development of environmental mitigation and monitoring plans (EMMPs);

c) Integration and implementation of EMMPs in work plans and budgets;

d) Integration of compliance responsibilities in prime and sub-contracts and grant agreements;

e) Assurance of sub-grantee and sub-contractor capacity and compliance;

f) FHP team environmental compliance oversight and monitoring;

g) 22 CFR 216 documentation coverage for new or modified activities; and

h) Compliance with host country requirements.

As required by ADS204.3.4, USAID/Benin FHP team managing this activity will actively monitor and evaluate whether environmental consequence unforeseen by this IEE arise during project implementation and modify or end activities as appropriate. Further, if additional activities not covered by this IEE are added to the activity, an amended initial environmental examination will be prepared and approved prior to implementation of activities.

BACKGROUND AND PROGRAM DESCRIPTION

Purpose and Scope of the IEE

This IEE provides the initial review of all planned activities to be implemented under the Benin Health Program BHP. In accordance with 22CFR216, this IEE provides the first review of all planned activities with respect to environmental impact potential and recommended threshold determinations.

Background and Activity Description

Good health is essential to improved productivity, higher incomes and reductions in poverty in Benin.

Benin’s poor health status is evidenced by high infant, under-five, and maternal mortality and morbidity, and high fertility. This is costly to individuals, families, and communities, and ultimately to the nation as it tries to respond to the chronic burden of disease and reduced productivity. Benin’s poor health indicators are due to low access to and use of high impact health services and poor health behaviors. Therefore, achieving the USAID/Benin Health Development Objective (DO), “Increased Use of High Impact Health Services and Healthy Behaviors” with particular focus on the health of the most vulnerable groups (e.g. infants and children under five, women of reproductive age) is essential to improving and sustaining health status.

The Benin Health Project (BHP) is a five year project with the goal of reducing preventable deaths among vulnerable populations through increased use of high impact health services and healthy behaviors at the community level. This goal will be achieved through programming in three component areas:

1. Delivery of an integrated package of high-impact health service

2. Improved preventative and care seeking behavior in communities and

3. Improved performance of key health systems.

These three components have been shown through research and best practice, both internationally and in Benin, to be effective in delivering high-impact health interventions.

The BHP and Health DO have established three (3) Intermediate Results (IRs) which will together lead to achievement of national-level results. They are:

1. Integrated High Impact Health Services: Improved delivery high impact health services

2. Social and Behavior Change Communication: Improved preventive and care seeking behavior of empowered communities.

3. Health Systems Strengthening: Improved Performance of Key Health Systems

Sub-purpose/IR 1: Improved delivery of integrated high-impact health services

A major constraint to improving the health status of Beninese is the limited coverage of high impact health services. One barrier to access is limited knowledge of the availability and need for timely use of services. This will be addressed through Component 2, SBCC messages and dissemination. Other barriers to access, such as high cost and poor quality, will be addressed under Component 3, Health Systems Strengthening. Remaining major barriers to access will be addressed under this component.

USAID and other development partners have provided support for expanding community-level services using various health care models and mechanisms with some success. Specifically, USAID/Benin has supported outreach through improved service delivery through community health clinics, CHWs, and campaigns. However, HIHS coverage is still not sufficient to meet need. To the extent feasible and appropriate, integration of HIHS will continue under the BHP.

Sub-sub-purpose/IR 1.1: Improved service delivery performance of private sector providers

1.1a Increased number of private sector providers deliver high quality, high impact health services

Many Beninese avail themselves of private, for-profit, health services rather than, or in addition to, those available through the public system. This includes commercial for-profit clinics and hospitals as well as those run by NGOs, faith-based groups, and traditional healers. The quality of private sector services varies, but many instances of poor quality have been documented.1 USAID has not engaged extensively with the private (non-social marketing) sector to date, but PDT analysis identified this as a programmatic gap and missed opportunity under the previous USAID health portfolio. USAID has an existing relationship with a network of private providers called the Private Sector Platform, and the BHP will use this network as one way to improve the quality of services delivered by private sector providers (for example, through professional updates, training, franchising, technical assistance on business development, providing access to credit for clinic improvement or the acquisition of equipment, etc.). Anticipated outputs include:

● Expanded number of for-profit private health providers offer high quality, high impact health services.

● Expanded number of NGO and faith-based health service providers offer high quality, high impact health services.

1.1b Increased social marketing outlets for information, products, and services

A proven way to reach populations, particularly in urban areas, with key high-impact products and services, as well as SBCC messages, is through social marketing. The BHP intends to further expand social marketing to urban and peri-urban areas and beyond as sales outlets permit. Socially marked products will include, for example, family planning products, ORS zinc, mosquito nets, and point of use water treatment tablets. Anticipated outputs include:

1 Benin Private Health Sector Assessment. Abt. Associates/SHOPS Project. Carlos Cuellar, Andrew Carmona, Andrea Harris, and Piotr Korynski March 2013.

● Increased number of outlets for socially marketed products and services.

● Increased sales of socially marketed high-impact products and services

● Improved and expanded contributions of social marketing outlets and organizations in developing and disseminating SBCC high priority messages and materials.

Sub-sub-purpose/IR 1.2: Improved service delivery performance of public sector providers

1.2a Increased number and improved quality of high impact health service sites at the facility and community levels

Community level health services start at the community level clinics, which are the public health system’s main vehicle for the delivery of primary health care. Improving the functioning and technical capacity of health clinics will be one approach to expanding access to an integrated package of HIHS for maternal and child health. Another will be strengthening the CHWs who extend access to HIHS to the household and individual levels. Additionally, the BHP will support outreach strategies such as mobile outreach and campaigns that extend health services to vulnerable populations. These strategies to expand and improve delivery of HIHS will build on USAID’s previous work strengthening health clinics, supporting service delivery campaigns, and successful activities with CHWs. Anticipated outputs include:

● Improved quality of HIHS delivered at community-level clinics

● Community health worker service sites expanded and quality improved

● Community health workers engaged in promoting the use of HIHS and healthy behaviors

1.2b Special initiatives, including mass distribution for neglected tropical diseases, and targeted activities to address selected infectious diseases

Some activities will focus geographically and technically on specific areas based on the epidemiology of key diseases and vectors causing morbidity and mortality in Benin.

For example, many Beninese are at risk for contracting selected Neglected Tropical Diseases, including lymphatic filariasis, onchocerciasis, schistosomiasis, soil transmitted helminthes, and trachoma. These NTDs significantly contribute to malnutrition and cause morbidity in certain geographic areas. USAID will conduct annual mass treatment campaigns in specific geographic areas, which provide drugs to treat NTDs to the entire population in those areas, with the goal of controlling and ultimately eliminating these diseases.

In HIV/AIDS, the BHP will focus on the areas, including major transportation routes, where groups at high risk for contracting HIV are found.

Indoor Residual Spraying (IRS) activities to kill the mosquitoes that carry malaria will focus on the geographic areas with the highest prevalence of malaria and single peak season, which can benefit the most from this intervention. Data for determining the appropriate geographic focus for IRS is still being collected, and the geographic focus for the activity will be determined during the implementation of the BHP.

Some activities focused on the prevention of Ebola and other pandemic threats will have national coverage, such as training of public sector health workers, while others will be focused geographically: for example, border control activities will be focused on the land borders, the sea port, and the airport; while SBCC activities may be focused on communities where the first case of a pandemic may present, such as border communities and major travel routes into the country.

Anticipated outputs include:

● Ebola prevention training conducted and appropriate equipment provided to the 14 most used land border crossings, the seaport, and the airport.

● IRS conducted in over 250,000 structures annually, protecting over 780,000 people.

● HIV/AIDS counseling and testing conducted for 20,000 people.

1.3. Strengthen Public-Private Partnerships for the provision of HIHS

Strong partnerships between the public and private sectors are essential in a country where health service provision is about evenly split between the two sectors.

1.3a Strengthened referrals and follow up

Prompt and appropriate referrals of complicated cases are essential to reducing morbidity and mortality. Research shows that many maternal, child, and infant deaths could be avoided if patients with life-threatening conditions were immediately referred to appropriate care. There are many challenges to establishing a functioning referral system, including availability of referral facilities, correct diagnosis, delayed care-seeking, perception of need and urgency on the patient’s part, unavailability of transportation and/or funding for transportation, and data collection, monitoring and supervision. The BHP will work to address these challenges.

Anticipated outputs include:

● Clients referred for services to a higher level of service provider go for services.

● Referral sites provide feedback to referring site on services provided and additional follow-up required.

● Private sector providers (traditional healers, pharmacists, etc.) refer to the public sector (or other qualified facility) when appropriate.

● Clients referred for services to a higher level of service provider go for services.

1.3b Improved regulatory environment for private sector providers

A 2013 assessment of the private health sector in Benin identified a restrictive policy and regulatory environment as one of the major factors inhibiting the development of the sector.2 This included:

overregulation and over-control of the private sector, overly restrictive regulations and registration requirements, and a policy environment not conducive to establishing group practices or provider networks. The GOB MOH is responsible for all health care in Benin, including that provided through the private sector. The BHP will work with the MOH to ensure that the private sector is able to both provide quality health care that meets national standards, and establish and conduct business without undue hardship. At the same time, BHP will work with the private sector to assist providers in complying with MOH regulatory and technical guidelines, and in advocating for the private sector at the national level. Activities may include advocacy for the streamlining of registration requirements, technical assistance to private providers on registration, advocacy for the deregulation of prices, and other interventions. Anticipated outputs include:

● Increased number of private providers registered.

● Strengthened capacity of professional orders and the private sector platform.

Sub-purpose/IR 2: Improved preventive and care seeking behavior of empowered communities.

This sub-purpose will support improved demand for quality health services and improved knowledge of preventive and care-seeking behaviors (healthy behaviors) at the individual, household, and community levels. Examples of health behaviors include hand-washing, breastfeeding, care-seeking for a child with fever, and attending antenatal care. Additionally, it will support strengthened community contributions to health decision making and health finance.

Sub-sub purpose/IR 2.1: Improved knowledge and attitudes about healthy behaviors among vulnerable populations

In Benin a large number and variety of organizations and groups have engaged in social and behavior change communications activities. Traditionally, there has been a heavy use of local radio for message dissemination. Few assessments of the effectiveness in regards to knowledge and attitudes among men and women of these efforts have been conducted. There has been limited capacity transfer from the central to health zone and commune levels to plan, monitor and adopt messages to meet local needs. Practitioners and development partners agree that the SBCC capacity of the national level down to the community level needs development and reinforcement and the evidence-base of SBCC interventions, particularly in regards to addressing the determinants of individual and social behavior.

2.1a Strengthened evidence-base for SBCC interventions for HIHS through formative research, monitoring and evaluation

2 Benin Private Health Sector Assessment. Abt. Associates/SHOPS Project. Carlos Cuellar, Andrew Carmona, Andrea Harris, and Piotr Korynski March 2013.

SBCC approaches, materials and other tools in Benin have been criticized for lack of strong formative research and effective monitoring and evaluation of their roll out, use and impact on behavior change at the individual and family level and on norm change at the community level and above.

USAID/Benin partners that have worked at the community level have produced SBCC materials for specific target audiences and high impact health services and programs. However, with some exceptions, they have not employed strong formative research techniques, monitoring, or evaluation.

Under the BHP all partners who engage in SBCC approaches, materials and tools will support strong formative research. All partners who support dissemination of SBCC approaches, materials and tools, will monitor their activities and, as appropriate, evaluate impact. Anticipated outputs include:

● Capacity of local partners developed to conduct SBCC-appropriate formative research, monitoring, and evaluation of impact.

● Formative research conducted for all high priority SBCC activities and campaigns.

● Evaluations conducted of all high priority SBCC activities and campaigns.

2.1b SBCC messages, approaches, materials and tools developed and produced for use at different levels of the health care system

Approaches, materials, and tools will be better adapted to the Beninese context and the diversity of cultural groups. Anticipated outputs are:

● Messages developed and tested for a variety of media including local media and for interpersonal communications support.

● Guidelines for use of SBCC materials and tools prepared to support use at all appropriate level of health system (focusing on community-level).

● Materials and tools adapted and produced for use at community level.

● Messages for mass media, including local community radio, disseminated to mass media outlets.

2.1c Appropriate, commune-led integrated communications campaigns implemented. A national Interpersonal Communications Plan for high impact interventions exists with identified key messages and communication channels. It is designed as a toolkit for planning and implementation at the commune-level. The BHP will emphasize the dissemination of messages and materials at the community level, and reinforcement of timely use of HIHS and healthy behaviors in all service delivery contexts.

Anticipated outputs include:

● High priority messages and related materials and tools disseminated at:

● Health facilities

● Community/household level (through CHWs)

● Mobile/outreach

● Accredited private sector franchises, offices, etc.

● Social marketing outlets

● High priority messages disseminated through local community radio and other local media, as well as through national-level mass media as appropriate.

● High priority messages provided through interpersonal communication, social networks, and other appropriate media.

Sub-sub-purpose/IR 2.2: Community contribution to health decisions and finance strengthened.

The sub-sub purpose will strengthen the capacity of civil society, local NGOs, community members, and other actors to: 1) advocate for increased budget transparency at the local level, increased allocations for health, and increased use of HIHS and healthy behaviors; and 2) demand accountability and transparency in health service provision, promotion, and financing from local health managers and authorities, and from locally elected leaders.

Additionally, within this sub-sub purpose, the BHP will work with communities and families to ensure gender equality in health care decision making, and specifically to increase women’s empowerment and agency over health care decisions affecting them and their children.

This sub-sub purpose will build on USAID’s previous work in strengthening community participation in health care management/decision making. Anticipated outputs include:

● Communities empowered to advocate for health budgets, accountability, and transparency.

● Women have greater agency over health care decision making for themselves and their children.

Sub-Purpose/IR 3: Improved Performance of Key Health Systems

Key health systems must function well at all levels of the health care pyramid to effectively ensure the delivery of quality health services. For example, family planning services cannot be offered at the community level if the national contraceptive commodity logistics system does not function smoothly. Family planning commodities must be accurately quantified, ordered in a timely manner, and distributed from the national to the community level to ensure a steady supply of products at service delivery points. Other key health systems include the HMIS, and governance and accountability. The BHP will focus on strengthening decentralized health systems and health management at the community, health zone and departmental levels. Additionally, the BHP will support the strengthening of key national systems required for the effective delivery of decentralized health services.

Sub-sub purpose/IR 3.1: Essential commodities more available at service delivery points

Challenges exist with the national commodity management system, including limited capacity of drug procurement and management personnel, lack of reliable commodity transportation and storage to the community level, weak logistics information reporting, and limited capacity in commodity forecasting. As a result, stock-outs of life-saving commodities are frequent at all health service delivery points.

This sub-sub purpose will address challenges in the pharmaceutical and commodity management system from the national to the community level. Support will be provided to train personnel and reinforce commodity transportation, storage, quantification, and forecasting. Additionally, the project will address gaps in logistics management information for decision-making. This will build on USAID/Benin’s previous work with the commodity management system, including a comprehensive assessment of the system conducted in 2015. Anticipated outputs include:

● Improved availability and quality of essential health commodities, including malaria, family planning and maternal and child health commodities, through improved forecasting, quantification and supply planning

● Improved availability and quality of logistics management information on pharmaceuticals and other health commodities

● Strengthened capacity of the MOH and other relevant actors in health commodities and supply chain management.

● Strengthened coordination among major actors in the commodities management system.

Sub-sub purpose/IR 3.2: Data from health management information system used effectively for evidence-based decision making

Health management information systems in Benin are encumbered by multiple monitoring and reporting procedures, including different registers and processes for capturing and reporting service delivery statistics. Monthly reports are not systematically processed and forwarded up the system, nor are data systematically used at community, health zone, or departmental levels for internal analysis and decision making. Reporting of services provided by CHWs and private sector providers is not routinely done.

This sub-sub purpose will strengthen HMIS by improving the quality of data collection and use. It will support improved processes for capturing, analyzing and reporting data, as well as use of data to the community level for better decision-making for planning and budgeting, human resource management, and the provision of quality goods and services. It will also strengthen data reporting and use in the private sector. Anticipated outputs include:

● Improved reporting of service statistics from health facilities and CHWs to other levels of the health system.

● Improved use of data and evidence to better manage and direct resources.

● Improved data use and reporting from private sector health providers.

Sub-sub purpose/IR 3.3: Strengthened health governance including improved management, leadership, and accountability

A transparent and accountable governance structure is a critical determinant of a strong health system, and is a necessary component to support strong country ownership and sustainability. This sub-sub purpose will support improved governance, particularly at the local level. For Benin’s decentralized health system to function well and achieve desired health outcomes, local health management and accountability systems need to be reinforced. This sub-sub purpose will support and strengthen the management, accountability, and transparency of local health managers (clinic-level) and authorities (e.g. zone/department).

This also addresses the need to strengthen national and local level policy development and implementation through open, participatory and evidence-based processes. It will support the development and implementation of relevant policies and the appropriate use of policy tools at the national, district and sub-district levels.

This sub-sub purpose is linked with Sub-sub-purpose 2.2: “Community contribution to health decisions and finance strengthened”. Under 2.2, the BHP will empower communities to advocate for involvement in health care provision at the local level, and to demand accountability and transparency in health service provision. 3.3 capacitate health authorities to be responsive to these demands from local communities.

This sub-sub purpose will build on USAID’s previous work in strengthening health management at the decentralized level, as well as community participation in health care management/decision making. Anticipated outputs include:

● Evidence-based management and governance tools and approaches used at all levels.

● Improved planning, management and accountability systems at the health service delivery, health zone, and department levels.

● Improved management processes to increase healthcare access, availability and affordability.

Although the BHP emphasizes the three health systems areas above, other aspects of the World Health Organization HSS pillars (e.g. human resources for health, health finance) will be integrated into BHP activities in a limited way. For example, both the quantity and quality of human resources for health will be addressed through BHP activities such as in-service training and supervision.

Additionally, BHP will advocate for select health policy changes which will have an impact on the implementation of HIHSs, and BHP’s health governance activities will support the improved use of and accountability for health finance at the local level.

COUNTRY AND ENVIRONMENTAL INFORMATION (BASELINE INFORMATION)

Benin Physical and Socio-Economic Profile

Benin is a small country with total area of 112,620 sq. km. (approximately the size of Pennsylvania). It is bordered by Togo to the west, Nigeria to the east and Burkina Faso and Niger to the North. To the south, Benin adjoins the Gulf of Guinea along a 125 km. coastline.

There are four distinct geographic and topographic zones in Benin:

1) The Mountainous region (associated with the Atakora mountain range in the northwest Benin), the main watershed for Benin and source for the Oueme, Pendjari and Mekrou rivers;

2) The Coastal zone, a relatively narrow strip of land that contains all of the lagoons and some of the most important lakes in Benin;

3) The Plateau region made up of clay and sand deposits that is found just north of the coastal zone and continues about 100 km. inland; and

4) The peneplain of Benin (large plateau) that increases in elevation very slowly from south to north.

Benin is covered by about 333 sq. km of lakes and lagoons. The river system is extensive and totals 3050 km. in length. Benin has three climatic zones. The southern zone is humid and has four seasons (two wet, two dry); this zone contains the best soils, vegetative growth and the highest levels of biodiversity. The central zone has two seasons. The northern zone is the driest region and has two seasons.

Benin is a poor country with low health and education standards. Benin’s health status is among the lowest in the world. Infant, child and maternal mortality rates, although falling, are among the highest in West Africa and the fertility rate remains high. Benin’s population is projected to double in less than 25 years, adversely affecting the gains of economic growth and placing stress on its limited social infrastructure. About 40 percent of Benin’s population of nine million is urban, while about half live in the southern part of the country, which represents only about 10 percent of the total land area. As in many West African countries, a large percentage of the population is young; 45 percent of Benin’s population is 15 years old or younger. Illiteracy rates are also high, at about 70 percent. The economy of Benin is highly dependent on subsistence agriculture, cotton production, and regional trade.

Benin’s major development constraints include a lack of infrastructure, accelerated urbanization, increasing unemployment, deforestation, soil degradation, and environmental pollution. Corruption continues to pose a serious threat to long-term development efforts although there is some limited government action to combat the problem. The most important environment issues currently facing Benin include inadequate supplies of potable water, low access to sanitation, poaching (which threatens wildlife populations), deforestation, and increasing desertification. Pressure from rapid population growth is a significant contributing factor to these problems.

Benin Health Sector Profile

The majority of health services in Benin are delivered by public sector facilities and practitioners. The public health workforce experiences rapid turnover, leading to inconsistent delivery of services and improperly followed protocols. Delays in approving and disseminating regulatory texts and weak management and planning capacity hamper effective implementation. The public sector alone cannot meet the demand for health products and services in Benin. The private sector, which provides about 35 percent of medical care, is largely unregulated.

The public health system is divided administratively into three levels: central, regional, and peripheral (where the Health Zone is located) community. Services are provided at four levels:

regional referral hospitals; communal health centers and urban health centers; arrondissement health centers; and village health units. There is a disproportionately high concentration of health workers in the southern part of the country.

Some health experts believe Benin serves as a regional model for the implementation of a cost recovery system based on the Bamako Initiative and a successful national drug distribution program. The mechanism for community participation is the election of representatives to community health management committees (COGEC/COGEA). Community financing accounts for approximately 30 percent of recurrent costs

Sustainability remains an important concern. Regions experience irregular supply of essential drugs and contraceptives, causing frequent stock outs. Although decentralization has been embraced as a principle, it has not been implemented effectively. While part of the goal of the existing decentralization legislation is to help improve the delivery of health services, weak management and planning capacity hampers effective implementation

Benin Environmental Policies and Procedures

Institutions for environmental management have developed slowly but steadily in Benin since the creation of the Ministry of Environment in 1992. The country adopted an overarching environmental law (loi cadre sur 1'environnement) in 1999 that places environmental impact assessment (EIA) at the core of the Government efforts towards achieving the goals of the sustainable development. The Benin Environmental Agency (Agence Béninoise pour l'Environnement [ABE]) was created in 1995 and shares the responsibility and objectives in the areas of environmental management and impact assessments with The Ministry of Environment and Natural Protection (MENP).

Through the late 1990s, EIA capacity building was emphasized as a key area of donor-funded environmental management efforts. These capacity building initiatives consisted of three main types of activities including (i) enacting a framework environmental law with specific requirements for EIA (and preparing and adopting implementation decrees for EIA law), (ii) developing sectoral guidelines for EIA, and (iii) holding several training workshops for the staff in line ministries, in consulting firms, and a few NGOs.3

The ABE also helped to create EIA cells in a number of ministries, including the Ministry of Health.

The main role of these units is to undertake the screening of the public investment projects included in the budget of each year, and recommend appropriate actions (under the guidance of the ABE) with the goal of mitigating any residual negative environmental or social impacts. Based on the sectoral guidelines prepared by the ABE, they provide guidance and supervision of EIA studies and mitigation plans. However, these units’ degree of activity varies across sectors: the Agriculture Ministry still retains important environment functions, and the units within the Transport Ministry and Water Directorate have been reinforced. Units in certain other ministries are hindered by lack of training and resources. Sector and regional focal points send monthly reports to ABE who elaborates an annual report, which is sent to both sector and regional focal points and shared online. 4

ABE has overall responsibility for ensuring that EIAs are carried out for all projects in accordance with national standards. The process is led and coordinated through the ABE’s Department of Environmental Assessment and General Studies. This department’s action strategy is based on the Environmental Impact Study Task Force. The Task Force is a forum of experts of national standing selected on the basis of their experience and skill from various public and private institutions. The Task Force meets at the request of the ABE, whenever it is necessary to study or prepare any EIA-related document or file. The EIA process in Benin consists of the following steps:

• Screening (pre-screening)

• Scoping

• Public hearings

• Analysis of the environmental impact study report

• The decision and

• Follow-up audit assessment

3 World Bank, 2004 Report No E897. (available online at: www-wds.worldbank.org)

3.0 POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS AND RECOMMENDED THRESHOLD

DETERMINATIONS INCLUDING CONDITIONS

For purposes of environmental review and analysis, planned illustrative activities under the Benin Health Program BHP are grouped into the following intervention categories.

Technical assistance and training in support of private and public health sector service delivery and access to health services Social marketing, education and social behavior change communication, SBCC Support for laboratory testing and implementation of quality control measures for anti-malaria medications at local and national levels Procurement, storage, management, distribution and disposal of public health commodities Indoor residual spraying Water supply and sanitation (including infrastructure)

Each category entails a number of illustrative activities. This section of the IEE evaluates the potential adverse environmental impacts of these activities. On this basis, recommended threshold determinations including conditions in some instances are made. Upon approval of this IEE, implementation of the attendant conditions becomes mandatory.

3.1 Potential Adverse Environmental Impacts of Health Care Service Delivery Due to Failure to Manage to Properly Manage Resulting Waste

Although small-scale healthcare activities provide many important benefits to communities, they can also unintentionally do great 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 have been discovered in fresh and marine waters globally, and even in small quantities some of these compounds have the potential to cause harm to aquatic life.

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

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.

TECHNICAL ASSISTANCE AND TRAINING IN SUPPORT FOR PRIVATE AND PUBLIC HEALTH SECTOR

SERVICE DELIVERY AND ACCESS TO HEALTH SERVICES

This BHP intervention category includes the following activities;

1. Technical assistance and training aimed at strengthening management capacity within the health system at the decentralized level through improved use of data for decision making;

including encouraging greater use of feedback from clients and other interventions aimed at improving management of human, financial, and other material resources.

2. Technical assistance and training for private and public sector health service providers to improve health care delivery and referral systems.

3. Technical assistance and capacity building for improved regulatory environment for private health sector operations including registration and licensing.

4. Provide technical assistance and training to ensure adequate supply chain management and improve commodities logistics management; includes working with health zones and health centers to create mechanisms for including commodities used at community level in their records, including commodities needed in their processes for drug resupply and working out strategies for actual supply and resupply of CHWs.

5. Training and technical assistance to local health organizations and authorities on the design and monitoring of BCC campaigns

6. Technical assistance, training and advocacy with local level health officials with requisite skills to be more accountable.

7. Technical assistance to private sector clinics including pharmaceuticals on improving health service delivery and business management.

Potential Adverse Impacts including Recommended Threshold Determinations Activities in this BHP intervention category are intended to improve and expand the delivery of and/or access to health care services. As detailed above, the delivery of these services presents a set of potentially significant adverse environmental impacts, particularly waste-related.

Where USAID support for service delivery is direct and this support fails to address waste management or to consider the capacity of medical facilities to properly handle, label, treat, store, transport and properly dispose of medical waste, unnecessary and potentially significant adverse impacts will result for which USAID bears full responsibility. Where USAID instead funds capacity-building for service delivery agents-e.g. public health workers, NGO staff-or for the entities that manage delivery of care (e.g. government ministries), USAID is likely to have less control over service delivery on the ground. Reduced control means that USAID's responsibility for adverse impacts is shared or attenuated but not eliminated.

The purpose of training is to influence the actions of practitioners and service delivery agents.

Appropriate management of health care waste depends heavily on individual actions of these practitioners and agents: e.g. do they conscientiously separate sharps and "red bag" waste? Training therefore must, as appropriate, address proper handling, use and disposal of health care waste.

Recommended Threshold Determination

Activities 1-4

Negative Determination with Conditions per 22 CFR 216.3(a)(2)(iii), is recommended for training, technical assistance and capacity-building support for health service delivery and access to health services. The conditions are as follows:

1. Training. Any training activities for professional health workers or community health workers involving techniques that would generate and require disposal of hazardous or highly hazardous waste (e.g. sharps, afterbirth from delivery, waste from screening for HIV or STIs.)

must include training in or ensure that the training curriculum covers best management practices concerning the proper handling, use, and disposal of medical waste, including blood, sputum, and sharps.

2. Direct provision of or support for ground-level service delivery. The BHP team and IPs must ensure, to the greatest extent feasible, that the medical facilities and operations benefitting from USAID support have adequate procedures and capacities in place to properly handle, label, treat, store, transport and properly dispose of blood, sharps and other medical waste and that norms and training include environmental health considerations. The ability of IPs and the BHP Team to assure such procedures and capacity is understood to be limited by its level of control over the management of the beneficiary facilities and operations. Proper Management" of health care wastes is defined as being in substantial conformity with the USAID Sector Environmental Guideline on Healthcare Waste (URL:

http://usaidgems.org/Sectors/healthcareWaste.htm) particularly the section titled, "Minimum elements of a complete waste management program." Other important references to consult for sound waste management practices are "WHO's Safe Management of Wastes from Healthcare Activities."

3. Support to health delivery & management systems must involve all feasible efforts to assure that these systems:

• address and support proper waste management (including handling, labeling, treatment, storage, transport and disposal of medical waste)

• address and support the capacity of medical facilities for waste management;

• prioritize environmental health considerations

It is understood that the USAID support to health delivery and management systems does not, in most cases, equate to direct USAID control over these systems. However, IPs must proactively advance these principles in their analysis and recommendations.

Activities 5-7

Activities in these categories are aimed at building capacity for effective operational and management of private and public health facilities. These activities by their nature and scope are not likely to result in any significant adverse environmental impact.

http://usaidgems.org/Sectors/healthcareWaste.htm

Categorical Exclusion per22CFR216.2(c)(i) for training, technical assistance.

SOCIAL MARKETING, EDUCATION AND SOCIAL BEHAVIOR CHANGE COMMUNICATION, SBCC

This BHP intervention category includes the following activities;

1. Technical assistance to support awareness raising efforts and information, education, and communication and behavior change communication activities to promote family health, including follow-up on LLITN use in homes.

2. Develop and manage a communications initiative to increase the knowledge of Beninese about HIV/AIDS, RH/FP, MCH and malaria, including accurate information to increase demand for and use of beneficial products and services and information to encourage and sustain healthy behaviors, such as the use of long-lasting insecticide treated nets (LLITNs) and prompt treatment of febrile illness.

3. Dissemination of behavior change communication materials including leaflets, brochures etc.

4. Provide support for enhanced BCC messages through the medium of radio and television

5. Hand washing campaigns.

6. Promotion of insecticide treated nets (LLITNs)

Activities under intervention areas 1-5 are targeted at communication, information dissemination and behavioral change messages. These activities by their nature, scale and scope are not likely to result in any significant direct/indirect adverse environmental impacts.

Promoting long lasting insecticide treatment nets for malaria control will not result in any direct adverse environmental impacts. However, there exists the possibility of end users of such promotional messages mishandling these LLITNs for either fish farming or fish smoking.

This practice has severe health implications for human health and pollution of water bodies.

Recommended Threshold Determination

Activities 1-5

Categorical exclusion pursuant to per22CFR216.2(c)(i) for education, technical assistance or training programs, 22CFR216.2(c)(v) document and information transfer is recommended for activities under this activity areas.

Negative Determination with conditions (per 22 CFR 216.3(a)(2)(iii)) is recommended for promotional messages for LLITNs subject to conditions that such messages should include best practice approaches in use and handling of LLINTs. This should include highlighting the environmental, health and safety risks of misapplying LLINTs for fishing and other ancillary activities.

SUPPORT FOR LABORATORY TESTING AND IMPLEMENTATION OF QUALITY CONTROL MEASURES

FOR ANTI-MALARIA MEDICATIONS AT LOCAL AND NATIONAL LEVELS

The Benin Health Program will provide…