Health IEE.pdf

INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ACTIVITY DATA:

Program/Activity Number: AA-685-12

Country/Region: Senegal/West Africa

Program/Activity Title:

Development Objective: Improved Health Status of the Senegalese Population

Funding Begin: FY2011 Funding End: FY2016 LOP Amount: $291,750,000

IEE Prepared By: William Roden, USAID/Senegal Current Date: 4/12/11

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

ENVIRONMENTAL ACTION RECOMMENDED:

Categorical Exclusion: X Negative Determination: X Positive Determination: Deferral: _________

ADDITIONAL ELEMENTS:

EMEMP: CONDITIONS X PVO/NGO:

Other Relevant USAID/Senegal Environmental Compliance Documentation:

Supplemental Environmental Assessment for Presidential Malaria Initiative—Indoor Residual Spraying (IRS) for Malaria Control in Senegal, 2010

Programmatic Environmental Assessment for Insecticide-Treated Materials in USAID Activities in Sub-Saharan Africa (ITM PEA).

PERSUAP, Signed, 2007 the “Pesticide Evaluation Report and Safer Use Action Plan” (PERSUAP) approved in 2008, the potential risk of the pesticides proposed for IRS to impact on the environment is negligible.

Previous Senegal Health IEE, 2006 – 2010, Signed 2006

Senegalese Health Commodities Regulations

Decret No. 2008-1007 Portant Reglementation de la Gestion des Dechets Biomédicaux. (Decree No. 2008-1007 regulating the management of biomedical waste) Translation of opening paragraph below:

The waste generated by the activities of care (medical and veterinary), research activities, and some industrial activities related to biomedical products can cause many harmful health effects and impact a clean environment.

SUMMARY OF FINDINGS:

Scope

USAID/Senegal will begin a new strategy in August of 2011. This is a new IEE and is intended to addresses the entire portfolio of ongoing and projected activities within the USAID/Senegal Health Program that are perceived to have an environmental impact.

In addition, this IEE sets out project-level implementation procedures intended to assure that conditions in this IEE are translated into project-specific mitigation measures, and to assure systematic compliance with this IEE during project and program implementation. These procedures are themselves a general condition of programs implemented under the Senegal Health Components, and their implementation is mandatory.

Programmatic Integration

The Health Office in Senegal has designed a system-wide approach to improving the health status of Senegalese families. It aims to strengthen the delivery of an integrated package of services (HIV/AIDS, Malaria, Maternal and Child Health (MCH), Family Planning and Reproductive Health (FP/RH), nutrition and water/sanitation) at the Government of Senegal (GOS) health facility level and the community level. The program will also strengthen the governance and operational performance of the overall health system and will promote healthy behaviors through various communication efforts and social marketing. The USAID/ Senegal Health Program will have five (5) program components: Health Systems Strengthening (HSS), Health Services Improvement (HSI), Community Health (CH), HIV/AIDS and TB, and Health Communication and Promotion (HCP). The integration of these program components aims to achieve the overarching Development Objective:

Improved Health Status of the Senegalese Population. For the purposes of this IEE these five components are further deconstructed into the following categories for environmental determinations.

1. Direct Capacity Building

2. Social Marketing & Behavior Change Communication

3. Epidemiological Surveillance and Reporting

4. Policy & Strategy Development

5. Support for Laboratory Testing and Quality Control of Pharmaceutical Commodities

6. Procurement, Storage, Management, and Disposal of Public Health Commodities

7. President’s Malaria Initiative (PMI) Component: Indoor Residual Spraying (IRS) & Bed- Net Distribution

Recommended Determinations and Conditions

This section reproduces verbatim the recommended determinations and conditions contained in the IEE. Lists of activities in each intervention category are omitted, however.

Note that Negative Determinations are recommended pursuant to 22 CFR 216.3(a) (2) (iii).

1. Direct and Capacity-Building

Recommended Determination(s) for this intervention type:

Negative Determination subject to the following conditions:

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 Health

Office 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 Health Office 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 Bureau for Africa’s Environmental Guidelines for Small Scale Activities in Africa (EGSSAA) Chapter 8, “Healthcare Waste: Generation, Handling, Treatment and Disposal” (encapafrica.org/SmallScaleGuidelines.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.

4. Community Health Workers. IPs must, as appropriate, include healthcare waste

(HCW) management messages and develop appropriate disposal mechanisms in home-based and community-based situations that are cost effective and safe.

Positive messages about personal and household hygiene, sanitation, and proper disposal of condoms and other potentially harmful materials should be delivered, as appropriate, along with standard health care messages, and these messages should be included in training, protocols, and guidelines.

2. Social Marketing and Behavior Change Communication (BCC)

Recommended Determination

Categorical Exclusion per 22 CFR 216.2 (c)(viii) However, the Health Office should encourage IPs to identity opportunities in behavior change interventions to include messages that emphasize the need to store potentially dangerous products out of the reach of children or animals; proper disposal of waste (e.g.

used condoms); and proper use of LLTNs and other insecticide-treated materials. Bed-net use for clothing, fish nets and wrapping should be discouraged, as should indiscriminate disposal of worn-out netting.

3. Epidemiological Surveillance and Reporting

Recommended Determination

Categorical Exclusion per 22 CFR 216.2 (c)(viii) NOTE: this categorical exclusion does NOT apply to surveillance activities that include collection of blood or body fluid samples, or otherwise generate hazardous or highly hazardous medical waste.

4. Policy & Strategy Development

Negative Determination subject to the following condition:

Implicated IPs and the Health Office must undertake all feasible efforts to assure that clinical norms and other aspects of service delivery codified through policy and planning support:

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

• The capacity of medical facilities for waste management;

• Prioritize environmental health considerations

It is understood that the final content of policy is the decision of host country government organs. However, IPs must proactively advance these principles in their analysis and recommendations.

Mandatory references. The USAID Bureau for Africa’s Environmental Guidelines for Small Scale Activities in Africa (EGSSAA) Chapter 8, “Healthcare Waste: Generation, Handling, Treatment and Disposal” (www.encapafrica.org/SmallScaleGuidelines.htm ) contains guidance which must inform the Office’s activities to promote proper handling and disposal of medical waste, particularly in the section titled, “Minimum elements of a complete waste management program.” Other important references to consult in establishing a waste management program are “WHO’s Safe Management of Wastes from Healthcare Activities” The ability of the Office to assure such procedures and capacity is understood to be limited by its level of control over the management of the facilities and operations that USAID/Senegal is supporting.

5. Support for Laboratory Testing and Quality Control of Pharmaceutical Commodities

Recommended Determination

Negative Determination subject to the following condition:

Appropriate management and disposal protocols must be developed for pharmaceutical and chemical wastes resulting from this activity. The implicated IP must assure their implementation, to the maximum degree consistent with IP control or influence over actions on the ground.

Appropriate management and disposal protocols are defined as being generally consistent with the mandatory references cited under section 3.5, above.

The GOS has outlined these regulations in the above-mentioned Décret No. 2008-1007 Portant Règlementation de la Gestion des Déchets Biomédicaux. It is expected that all IPs working in procurement, storage, management and/or disposal of public health commodities, including pharmaceutical drugs adhere to these national guidelines.

6. Procurement, Storage, Management, and Disposal of Public Health Commodities

Recommended Determination

A. For LLIN Activities:

Negative Determination subject to the following conditions, The implicated IP(s) is/are required to purchase and use only WHO-approved brands of long-lasting treated nets and adhere to all relevant stipulations made in the USAID Africa Bureau Programmatic Environmental Assessment for Insecticide-Treated Materials in USAID Activities in Sub-Saharan Africa (ITM PEA).

USAID/Senegal will investigate any cases of widespread misuse of LLINs. If USAID/Senegal discovers widespread misuse, they will work with USAID/Global Health in identifying mitigation measures (e.g., IEC/BCC to address misuse in fishing villages).

B. For all other activities in this intervention category:

Negative Determination subject to the following conditions:

1. Implementing partners conducting activities involving procurement, storage, management and/or disposal of public health commodities, including pharmaceutical drugs, immunizations and nutritional supplements, and rapid diagnostic tests for malaria should ensure, to the extent possible, that the medical facilities and operations involved have adequate procedures and capacities in place to properly manage and dispose of such commodities.

2. Consignees for any pharmaceutical drugs procured under this funding will be advised to store the product according to the information provided on the manufacturer’s Materials Safety Data Sheet (MSDS).

3. If disposal of any of these pharmaceutical drugs is required, due to expiration date or any other reason, the consignee will be advised that the preferred method of disposal is to return to the manufacturer. If this is not possible then follow WHO guidelines for Safe Disposal of

Unwanted Pharmaceuticals.

4. Disposal of packaging and other public health commodities will be treated using the guidelines provided in Environmental Guidelines for Small-Scale Activities in Africa (EGSSAA), Chapter 15: Solid Waste.

5. The GOS has outlined these regulations in the above-mentioned Senegalese Drug Policies Documents. It is expected that all IPs working in procurement, storage, management and/or disposal of public health commodities, including pharmaceutical drugs adhere to these national guidelines.

7. PMI Component: Indoor Residual Spraying (IRS) & Bed-Net Distribution

A. For IRS & LLIN Activities:

Negative Determination subject to the following condition, LLIN distribution activities are not expected to have an overall negative effect on the environment because they are accompanied by efforts to control the distribution and destruction of used bed nets. These conditions are spelled out in a pesticide evaluation report and safer use action plan (PERSUAP), developed under the Senegal Health Office, in April 2007, to address all USAID activities in Senegal that directly or indirectly support the distribution of insecticide treated bed nets. The PERSUAP was prepared in accordance with the guidance contained in the USAID Bureau for Africa’s “Programmatic Environmental Assessment (PEA) for Insecticide-Treated Materials in USAID Programs in Sub-Saharan Africa, 2006” Negative determination with conditions.

The recommendation for this negative determination is further supported by the March 2010 amendment to expand the Sector Environmental Assessment (SEA) specific to Indoor Residual Spraying (IRS) and the Indefinite Quantity Contract (IQC) to other regions of Senegal. This document is valid until March, 2015.

APPROVAL OF ENVIRONMENTAL ACTION RECOMMENDED:

Development Objective: Improved Health Status of the Senegalese Population

Director, USAID/Senegal___________________________________Date_____________ Kevin Mullally

CONCURRENCE:

Bureau Environmental Officer: ________________________________Date_____________ Bureau for Africa Brian Hirsch Approved___________

Disapproved ________

ADDITIONAL CLEARANCES:

Mission Environmental Officer__________________________________Date___________

Aminata N. Badiane

Health Office Leader_________________________________________Date___________ Akua Kwateng-Addo

Program Office Director, Acting _______________________________ Date____________

Christophe Tocco

OPTIONAL CLEARANCE:

Regional Environmental Officer________________________________Date___________

Robert Buzzard

Bureau Environmental Officer_________________________________Date___________ Bureau for Health Teresa Bernhard

INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ ACTIVITY DATA:

Program/Activity Number: New USAID/Senegal Health Program 2011-2016

Program Activity Title: Senegal Health Program

Country/Region: Senegal/Africa

Functional Objective: Improved Health Status of the Senegalese Population

Program Area: Health

Program Components: Health System Strengthening Health Services Improvement Community Health HIV/AIDS and TB Health Communication and Promotion

1.0 HEALTH PROGRAM DISCRIPTION

1.1 PURPOSE AND SCOPE OF IEE

This IEE addresses the entire portfolio of new activities of the USAID/Senegal’s Health Program.

Development of this single IEE for the Health Program was undertaken for organizational and programmatic reasons. Specifically, it should better enable the Health Office to oversee environmental compliance of the portfolio.

For purposes of analysis, this IEE synthesizes anticipated Health Program activities under the office’s various projects and initiatives into 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 for these activities.

In addition, this IEE sets out project-level implementation procedures intended to assure that conditions in this IEE are translated into project-specific mitigation measures, and to assure systematic compliance with this IEE during project and program 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 DESCRIPTION OF THE HEALTH PROGRAM

The Health Program falls within the Foreign Assistance Reform (FAR) framework under the “Investing In People” Functional Objective. The USAID/Senegal’s Health Program is under the Health Area (Program Area 3.1) and includes activities in the Program Elements of

HIV/AIDS (3.1.1), Maternal and Child Health (MCH) (3.1.6), Family Planning and Reproductive Health (FP/RH) (3.1.7), and Malaria (3.1.3) within an integrated, system-wide approach to Health Systems Strengthening. It includes interventions at the Government of Senegal health facility level and the community level. It also includes behavior change communication and social marketing.

The President’s Malaria Initiative (PMI) has achieved a national scale malaria prevention and treatment program in Senegal and includes the application of indoor residual spraying (IRS) to the prevention activities being implemented.

1.2.1 PROGRAM OBJECTIVES & INTERMEDIATE RESULTS

This IEE is directed at the entire proposed Development Objective for Health Programming:

The USAID/Senegal Health Program is designed specifically to achieve three (3) Intermediate Results: IR 1: Increased Use of an Integrated Package of Quality Health Services and IR 2: Improved Health Seeking and Healthy Behaviors and IR 3: Improved Performance of the Health System.

1.2.2 DESCRIPTION OF ACTIVITIES:

The Development Objective will be implemented through several cooperative agreements and/or grants under three key intermediate results (IR). This objective is comprised of the following three intermediate results:

IR 1: Increased Use of an Integrated Package of Quality Health Services IR 2: Improved Health Seeking and Healthy Behaviors IR 3: Improved Performance of the Health System

In working towards achieving these three (3) IRs, and their sub-IRs, USAID/Senegal believes that the quality of health related services and information offered to the population will improve. Information as referenced in this context refers to counseling, IEC/BCC and social marketing information, messages promulgated by community health volunteers regarding health behavior (e.g. when to seek care, use of family planning products and services, sleeping under insecticide-treated bed nets, Female Genital Cutting, and stigma reduction for HIV/AIDS).

1.2.3 KEY HEALTH PROGRAM COMPONENTS

These IRs will be achieved through six (6) key program components which include:

1. Health Systems Strengthening Program Component (Geographic focus: 9 regions: main activities in Kolda, Sédhiou, Ziguinchor, Louga; and targeted technical assistance with Belgian Technical Cooperation in Thiès, Diourbel, Kaolack, Kaffrine, and Fatick)

The principle objective of the Senegal Health System Strengthening Component is improved performance of the decentralized public health system of Senegal, supported by effective and efficient program policies, planning and budgeting at the central level of the Ministry of Health. Specific interventions are focused at different levels of the health system. The first sub-component is to improve the functioning and performance of regional and district health management systems and teams. The introduction of Performance Based Incentives is expected to be an important aspect of this effort. This award will also help alternative financing mechanisms such as community based health maintenance organizations strengthen their reach and sustainability. At the national level, the Recipient of this award will be the key health partner participating in policy dialogue and reforms to improve results across the USAID health portfolio.

2. Health Services Improvement Program Component (Geographic focus: nation-wide for malaria; minimum package in 10 regions; Thies, Diourbel, Kaolack, Kaffrine, Fatick, Kolda, Sédhiou, Ziguinchor, Louga, and St. Louis)

The principal objective of this component is increased use of an integrated package of quality health services. The focus of intervention is on health posts and health centers, with strong linkages to community based services and to regional hospitals to ensure a well-coordinated continuum of care for women and children under five. The Recipient is expected to improve not only availability of the integrated package of services but also improved functioning of the facilities and teams that deliver these services. The Recipient is expected to enable optimal performance of health posts and health centers throughout Senegal, to help them establish well-functioning linkages and support to community health programs, to strengthen their technical linkages and referral networks with regional hospitals, and to assist in strengthening the relationship of these facilities with district and regional health teams in a joint effort to support improved health programs and outcomes.

3. Community Health Program Component (Geographic Focus: Nationwide)

The Community Health Component of the USAID/Senegal Health program is essential to the achievement of the USAID/Senegal Development Objective in the Health Program Area. It is specifically designed to contribute to Intermediate Result (IR) 1: Increased use of an integrated package quality health services.

This component is predicated on the hypothesis that providing communities with the tools (including information, training, access to services and commodities) to prevent and treat their most pressing health threats has the potential to immensely increase access to quality care and life-saving interventions. This component will improve access and quality of community health services and information; to enable the active engagement of beneficiaries in seeking health care or responding to care options at the community level throughout Senegal; and to contribute to the establishment of well-functioning technical linkages and referral networks for health huts and strengthening the relationship of health huts with district and regional health teams in a joint effort to support improved health programs and outcomes at all levels. This component ensures the continuum of services starting from the community to public health services. This project continues to build on USAID/Senegal’s experience with and the GOS/MOH support for this approach in assuring access to the package of information, products and services for underserved Senegalese. Information, products and services will encompass FP/RH, MNCH, nutrition, malaria, TB (information only), HIV/AIDS (information only), and water, sanitation and hygiene.

4. Health Communication Program Component (Geographic focus: nation-wide;

product specific)

The Recipient will apply state of the art social marketing approaches in communication to market USAID-supported family planning, water purification and other commercial products. Activities will encourage the behavior changes needed to adopt the use of these products to improve health in the priority technical areas of reproductive health, maternal and child health, malaria, HIV/AIDS, tuberculosis (TB) and other infectious diseases, maximizing the use of relevant approaches, materials and media products already developed and used successfully in Senegal. In conjunction with other implementing partners, this component will also be expected to engage NGOs, the private sector, and community and elected leaders to support improved health behaviors and outcomes, as a part of social marketing strategies.

5. HIV/AIDS and TB Program Component (Geographic Focus: 7 regions; Thiès (Mbour), Kaolack, Kedougou, Ziguinchor, Sedhiou, Kolda, Diourbel (Touba), and Dakar)

The principal objective of the HIV and TB Component of the USAID/Senegal Health Program is to provide targeted, relevant technical assistance and other types of support to the Government of Senegal and its partners in order to maintain a low national prevalence of HIV, improve the quality and availability of treatment, care and support of People Living With HIV/AIDS (PLWHA) and improve detection and treatment of TB.

Strengthening national capacity to plan and oversee these programs and advocate for appropriate policies is key to the success of this component.

6. PMI-Specific Component (Geographic focus: nationwide for LLIN coverage:

targeted regions for indoor-residual spraying)

In addition to malaria-related activities to be carried out under the HSI component and Community Health Program Components, the PMI is supporting the nationwide distribution of LLINs and the promotion of their use for the prevention of malaria. The PMI is also supporting the indoor residual spraying (IRS) of long-lasting formulations of insecticides in six districts. The choice of districts and insecticides will vary from year to year based on disease epidemiology, program funding, and insecticide resistance patterns.

2.0 COUNTRY AND ENVIRONMENTAL INFORMATION

The Health Program will be implemented in all Regions of Senegal. The following provides a brief description of the biophysical and socio-economic aspects of Senegal.

2.1. Country Climatic, Physical and Ecological Background

Senegal is the most western country in the Sahel. It is bound in the West by the Atlantic Ocean, in the North by Mauritania, in the East by Mali, in the South-East by Guinea, in the South-West by Guinea-Bissau, and it enclaves The Gambia. It comprises an area of 196,722 km2 which is mostly flat, without any pronounced relief.

2.1.1 Climate: Senegal has a harsh climate with generally high temperatures, and low to moderate rainfall. Rainfall is irregular both in distribution and frequency. The rainy season is limited to a seasonal monsoon, wetter in the South than in the North. Average annual rainfall varies between 200mm and 400mm from July to September in the North, 400- 700mm in the center, and 700-1,000mm from May to October in the South.

2.1.2. Surface Water: Senegal is cut by four major rivers: Senegal, Sine-Saloum, Gambia and Casamance. Because of the seasonality of the rains and the high evaporation rate, there are practically no permanent surface bodies of significance except for the Lac de Guiers which is replenished yearly by the floods of the Senegal River. The decrease in rainfall over the last 40 years has also affected flood volumes of the main rivers. For example, volumes in the Senegal River have decreased from more than 30 billion m3 to less than 20 billion m3, the lowest being in 1984 with less than 10 billion m3.

https://www.cia.gov/library/publications/the-world-factbook/geos/sg.html

2.1.3. Ground Water: Groundwater reserves are relatively abundant in Senegal. These include numerous shallow aquifers replenished by rain waters, and a deeper Maestrichian formation that underlies most of the country.

2.1.4. Soil Fertility: Except along the Senegal River Basin where the soil texture tends to be higher in clay content, the soils of Senegal range from dry sandy soils in the north through the tropical ferruginous soils of the central Sahelo-Sudanian region to the ferralitic soils of the Sudanian region in the South. Overall, soil fertility is low and soils are also generally fragile, making them highly susceptible to water and wind erosion when disturbed.

2.2. Population: The population of Senegal is growing at the relatively high rate of 2.8 percent per year and is currently estimated to be 12.5 million. As a result of this rate of increase, nearly 45% of the population is under the age of 15. The average population density was 57/km2 in 2006 and in the past 4 years has risen to 64/km2; outside of urban areas, population density is very uneven.

The second major feature of population is a sustained migration from rural to urban areas.

During the period from 2005 to 2010, the urban population increased at an annual rate of 3.1%. Such sustained growth naturally increases the environmental pressures in urban areas.

Senegal has been modestly successful in improving the physical quality of life since independence. Today, 69% of urban habitants use an improved sanitation system and 93% have access to improved sources of drinking water. However, these services are available to only 38% and 65%, respectively, of rural habitants1.

1 Population Reference Bureau, Senegal Demographic Data http://www.prb.org/Datafinder/Geography/Summary.aspx?region=30&region_type=2

Averaged for both sexes, current life expectancy in Senegal is 56 years. Child mortality (age 0 to 5) has decreased from 287 per 1,000 in 1971-75, to 121 per 1,000 in 2005 and to 85 per 1,000 in 2008. The 2005 Demographic and Health Survey (DHS) indicates that only 10.3% of women use modern contraceptives. HIV sero-prevalence among the general population is estimated at 0.7% in 2005.

The health care system in Senegal has also been plagued with the inconsistent quality of preventive and curative care and frequent unavailability of trained staff and essential products at health centers. Supervision of health services has been poor or non-existent, and the lack of local government support and involvement in health services remains a serious obstacle to improved quality.

2.2 SENEGAL HEALTH SECTOR PROFILE

Senegal, a stable, democratic country in West Africa, is politically and economically one of the strongest countries in the region, though much remains to be done on the road to development. Senegal has a population estimated at 12.5 million, over 40% of which is urban. The proportion of the population living below the poverty line is 62% in rural areas and 32% in Dakar1. Although substantial improvements have been achieved since the 1960s, Senegal’s indicators of human development remain unacceptably low with the country ranked 144 out of 182 countries worldwide on the United Nations Human Development Index2. The adult literacy rate is about 40%, while the primary school completion rate is almost 70%.

Approximately 43% of primary school graduates are girls, with the disparity growing even higher in the upper levels of the education system. The mean life expectancy is 56 years3.

With a population growth rate of 2.6 percent per year, the population will grow by over 6 million to approximately 19 million by 2025, challenging Senegal’s attempts to improve health, education, and other services and improve the well-being of its people and its environment. Although many health indicators, such as infant and child mortality, have improved in recent decades, they remain unacceptably high with many health challenges remaining as described briefly below. The leading causes of death for children under-five years of age include malaria, pneumonia, diarrheal disease and neonatal causes.

Infant and Under-Five Mortality: The Government of Senegal (GOS) recognizes the role that healthy families play in helping the country to realize its development goals. Senegal can count the significant reduction in infant and under-five mortality rates over the last five years among its great successes. According to the 2008/2009 Malaria Indicator Survey (MIS), infant mortality dropped from 61 to 54 per 1,000 live births and under-five mortality decreased from 121 to 85 per 1000 live births, compared to the 2005 DHS (a 30% reduction)4. This significant decrease follows several decades of relatively stagnate rates and indicates progress being made in scaling up health interventions, especially but not exclusively the dramatic nationwide scale up of measles and malaria control interventions.

However, despite these significant declines much remains to be done to further reduce the still unacceptably high numbers of infants and children dying before age five.

1 Based on comparing the cost of a standard basket of food and non-food items to the per-captia annual consumption. République du Sénégal. Evaluation quantitative du DSRP-I (2003-2005), July 2007 2 Human Development Report 2009 : Senegal. Available on web at http://hdrstats.undp.org/en/countries/country_fact_sheets/cty_fs_SEN.html accessed 12 October 2010.

3 Ndiaye, S, Ayad, M. 2006. 2005 Senegal Demographic and Health Survey (DHS). Calverton, Maryland USA:

Centre de recherche pour le développement humain (Sénégal) and ORC Macro 4 Ndiaye, S, et al. 2009. 2008/9 Senegal Malaria Indicator Survey. Calverton, Maryland USA: Centre de recherche pour le développement humain (Sénégal) and Macro International

Maternal Mortality: Senegal’s maternal mortality remains high at 401/100,000 live births due to inadequate reproductive health services available and accessible to Senegalese women1. The GOS is scaling up the implementation of two proven methods to reduce neonatal mortality and reduce high maternal mortality namely the Active Management of the Third Stage of Labor (AMTSL) and the provision of Essential Newborn Care (ENC).

Family Planning: Despite slow but consistent decreases the total fertility rate remains high at 5.3 children per woman, while use of modern contraception is only 10.3% among married women of reproductive age. Although knowledge of contraception is high, women continue to have more children than they desire and unmet need for contraception is among the highest in the world at 31.6% of married women2. Recently the GOS has re-invigorated its support for reproductive health and, in particular, family planning as a method for reducing maternal and child mortality. The MOH has prioritized reducing the current fertility rate by supporting interventions to expand access to FP services in order to close the gap on unmet need and ultimately raise the contraceptive prevalence rate. Efforts are underway to reduce health system bottlenecks and socio-cultural barriers to FP and to expand access to contraceptive commodities and services through the public and private sectors.

Malaria: Senegal has made significant progress in the scale up of malaria interventions in recent years. The 2009 Post-Campaign Survey showed that 80% of households owned at least one insecticide-treated bed net (ITN) and 45% of children under five had slept under an ITN the previous night. Since 2010 the National Malaria Control Program has been distributing long-lasting insecticide treated bed nets (LLINs) to achieve universal coverage of all sleeping spaces in an effort to reduce malaria transmission. The proportion of targeted houses accepting indoor residual spraying has been >90%. Artemisinin-containing therapies and rapid diagnostic tests have been available at all health facilities since 2007 and in all health huts since 2009, with over 85% of suspected cases being tested and only confirmed cases being eligible for antimalarial treatment. The proportion of health facility consultations attributed to malaria fell to 3% in 2009 and the proportion of all in-hospital deaths due to malaria fell to 4.4%.3 In addition, the 2008 MIS found that parasite prevalence nationwide was 6% in children 6-59 months of age, although these results were obtained at the beginning of the low-transmission season and hide significant regional variation (from a low of 0% in Saint Louis to a high of 23% in Tambacounda).

The National Malaria Control Program has implemented an innovative home-based management of fever program to bring rapid diagnostic tests and malaria treatment to difficult access areas. Challenges remain in assuring consistent stocks of key products (SP, ACTs, and LLINs), strengthening surveillance systems, and managing malaria in the face of recurrent urban flooding.

Nutrition: Senegal has made improvements in this area, with some of the lowest rates of under nutrition among children under five in West Africa, but there is more work to be done.

Approximately 14% of children under five in Senegal are underweight, 20% are stunted, 8% are wasted and 31%4 of deaths are associated with under-nutrition. Chronic, moderate under-nutrition in this age group impairs intellectual capacity, educational performance, and productivity, and its carry-over into adulthood is a factor that leads to poor pregnancy outcomes or even maternal deaths, including dangerous levels of anemia and insufficient pelvic size. Micronutrient deficiencies are an important concern. Iron deficiency anemia remains extremely high throughout the country; 64% of women and 80% of children-five are

1 Findings from the 2005 Senegal Demographic and Health Survey, ORC Macro, November 2006 2 Findings from the 2005 Senegal Demographic and Health Survey, ORC Macro, November 2006.

3 Senegal National Malaria Control Program 2009 Annual Report 4 Africa Nutrition Chart books: Nutrition of Young Children and Mothers in Senegal. Findings from the 2005 Senegal Demographic and Health Survey, ORC Macro, November 2006 anemic1. The presence of goiter due to iodine deficiency, once considered endemic in south-east Senegal (34%), is declining due to concerted efforts to promote the use of iodized salt.

Only 41% of Senegalese households use adequately iodized salt. Vitamin A deficiency affects 61% of children under-five. Chronic under-nutrition (under-weight and stunting) differs by wealth quintile and region – higher among those in the poorest wealth quintiles and in the rural areas. The country is characterized by significant regional disparities in percentage of children underweight, e.g. 6% of children under five in Dakar are underweight compared to 32 % in Kolda. Wasting in Senegal is similar across wealth quintiles.

Water and Sanitation: Given the extremely high prevalence of diarrheal disease in Senegal, progress in water and sanitation has significant importance to decreasing morbidity and mortality, particularly in children under 5 years of age. Diarrheal related illnesses are the second leading cause of death for children under five, which accounts for about 40,000 preventable deaths each year in Senegal. The Government of Senegal began reforming its water supply and sanitation (WSS) sector in 1996 and since then has made substantial improvements in coverage and sector organization. As such, Senegal is on track to meet its Millennium Development Goal (MDG) targets for water by 2015, with lesser prospects for sanitation. In 2005, Senegal developed a programmatic approach to coordinate WSS stakeholders called Programme d’Eau Potable et d’Assainissement du Millénaire (PEPAM) or The Millennium Potable Water and Sanitation Program. PEPAM has been instrumental in setting Senegal’s progressive WSS sector policy and is an investment program that appears sufficient to meet MDG targets in urban and rural water access and sanitation facilities.

HIV/AIDS: Senegal presents a unique situation; praised for early commitment to open dialogue and proactive engagement towards HIV at the beginning of the world-wide epidemic, it has maintained one of the lowest adult HIV prevalence rates on the continent, estimated at 0.7% for adults 15-49 years of age, with 67,000 adults estimated to be living with HIV/AIDS2. Characterized by an epidemic concentrated among most-at-risk-populations (MARPs), the HIV/AIDS prevalence is approximately 19% among commercial sex workers (CSWs), 22% among men having sex with men (MSM), and 3% among women in the Ziguinchor region. No significant differences exist between urban and rural areas, though the regions in the Casamance have higher rates: 2% in Kolda and in Ziguinchor.

Despite being known for the openness and involvement of its religious community in the early years of the HIV/AIDS epidemic, recently increased negative sentiment towards certain high-risk groups, notably CSWs and MSMs has been evident. These sentiments could threaten Senegal’s gains and precipitate a more generalized epidemic. The National AIDS Council (Conseil National de Lutte Contre le SIDA, CNLS) is working to put in place a “watchdog” group to develop strategies to safeguard access to health care for these high-risk groups.

TB: TB continues to be a serious public health problem in Senegal. The 2009 World Health Organization (WHO) Global TB Report documents an increase in incidence from 110 to 119 per 100,000. This corresponds to 14,706 more TB patients in Senegal as compared to previous years with 53% of the TB burden found in Dakar. HIV prevalence among TB patients is 7%, or 10 times higher than in the general population (0.7%). Community awareness of TB remains low and consequently people do not seek treatment early. The procurement system is weak, which results in stock outs of laboratory commodities for diagnosis as well as TB drugs. Other challenges include: weak quality control at laboratories

1 Ndiaye, Salif, et Mohamed Ayad. 2009. Enquête nationale sur le Paludisme au Sénégal 2008-2009. Calverton, Maryland, USA : Centre de Recherche pour le Développement Humaine [Sénégal] et ICF Macro. (Malaria Indicators Survey) 2 UNAIDS/WHO Epidemiological Fact Sheet on HIV and AIDS for Senegal, September 2008. Available on web at http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_SN.pdf accessed 15 July 200918 May 2010.2009.

that perform TB tests; insufficient capacity at the regional treatment centers for the number of patients they have; and weak referral systems to direct suspected TB patients to the services they need. Despite these challenges the Government of Senegal’s commitment to tuberculosis prevention and control remains strong, with the National TB Program making progress in overall program management, access, and quality of detection and treatment.

USAID/Senegal plans to address these public health challenges through a Development Objective which aims to improve the health status of Senegalese citizens and support the country in reaching its Millennium Development Goals #1 (Reduced Poverty and Hunger), #4 (Child Health), #5 (Maternal Health) and #6 (Infectious Disease Control), by helping to reduce under-nutrition; reduce total fertility through increased contraceptive use; reduce infant, under-five mortality rates and the maternal mortality ratio; and, reduce deaths from malaria and the incidence of HIV/AIDS. This DO will be achieved between USAID/Senegal and the Government of Senegal and its implementing agencies, in concert with other donors, as well as all the other key actors in the Senegal health sector.

2.4 EXISTING ENVIRONMENTAL POLICIES

The policy environment for natural resource management and biodiversity conservation has improved over the last 10 years. Senegal now has a broad legal basis for environment and conservation, yet many of the laws are not yet fully applied and some contradictions remain.

Senegal has signed and ratified all the Rio international conventions. With USAID funding, a National Environment Action Plan (NEAP) was completed in 1997 that lays the framework for cooperation among all ministries for environmental policy and dialogue. This resulted in the new Environment Code that was established in 2001. The NEAP was also followed by the National Plan to Fight Against Desertification to develop specific actions to combat desertification. A Biodiversity Strategy was adopted that lays out priority areas for biodiversity conservation. The Decentralization Code of 1996 has had considerable impact on how the environment is managed as it transferred jurisdiction for natural resource management to local governments. The Forestry Code, revised in 1998, set conditions for the transfer of forest management to local governments which included the development of forest management plans. A new Forestry Action Plan was developed in 2005 to improve implementation of the Forestry Code. The Hunting Code is currently being up-dated and will experiment with local management of the protected areas. This corpus of Ag/NRM-related legislation and policy guidelines is well conceived but has yet to be fully applied.

3.0 POTENTIAL ENVIRONMENTAL IMPACTS AND DETERMINATIONS

The Health Office in Senegal has designed a system-wide approach to improving the health status of Senegalese families. It aims to strengthen the delivery of an integrated package of services (HIV/AIDS, Malaria, Maternal and Child Health (MCH), Family Planning and Reproductive Health (FP/RH), nutrition, and water/ sanitation) at the Government of Senegal (GOS) health facility level and the community level. The program will also strengthen the governance and operational performance of the overall health system and will promote healthy behaviors through various communication efforts and social marketing. The USAID/ Senegal Health Program will have five program components: Health Systems Strengthening (HSS), Health Services Improvement (HSI), Community Health (CH), HIV/AIDS and TB, and Health Communication and Promotion (HCP). The integration of these five sub-components aims to achieve our overarching Development Objective: Improved Health Status of the Senegalese Population. For the purposes of this IEE these five components are further deconstructed into the following categories for environmental determinations.

1. Direct Capacity Building

2. Social Marketing & Behavior Change Communication

3. Epidemiological Surveillance and Reporting

4. Policy & Strategy Development

5. Support for Laboratory Testing and Quality Control of Pharmaceutical Commodities

6. Procurement, Storage, Management, and Disposal of Public Health Commodities

7. PMI Component: Indoor Residual Spraying (IRS) & Bed-Net Distribution

Each component contains a number of activities. In this section, the potential impacts of these activities are analyzed, and 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.

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.

3.1.1 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.

3.1.2 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.