Annex 4 - BEO Approved IEE.pdf

USAID/KENYA

HEALTH PORTFOLIO 2022 – 2027

INITIAL ENVIRONMENTAL

EXAMINATION

CONTENTS

1.0 PROJECT/ACTIVITY DESCRIPTION 9

1.1 PURPOSE OF the IEE 9

1.2 ACTIVITY OVERVIEW 9

1.3 ACTIVITY DESCRIPTION 10

2.0 BASELINE ENVIRONMENTAL INFORMATION 16

2.1 LOCATIONS AFFECTED AND ENVIRONMENTAL CONTEXT (ENVIRONMENT,

PHYSICAL, CLIMATE, SOCIAL, THREATENED AND ENDANGERED SPECIES) 16

2.2 APPLICABLE AND APPROPRIATE PARTNER COUNTRY AND OTHER

INTERNATIONAL STANDARDS (E.G. WHO), ENVIRONMENTAL AND SOCIAL LAWS,

POLICIES, AND REGULATIONS 19

2.3 COUNTRY/MINISTRY/MUNICIPALITY ENVIRONMENTAL CAPACITY ANALYSIS (AS

APPROPRIATE) 19

3.0 ANALYSIS OF POTENTIAL ENVIRONMENTAL RISK 23

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

PROPERLY MANAGE RESULTING WASTES 23

3.2 POTENTIAL ENVIRONMENTAL AND SOCIAL IMPACTS PER INTERVENTION

CATEGORY 25

4.0 ENVIRONMENTAL DETERMINATIONS 31

4.1 RECOMMENDED ENVIRONMENTAL DETERMINATIONS 31

4.2 CLIMATE RISK MANAGEMENT 33

5.0 CONDITIONS AND MITIGATION MEASURES 33

5.1 CONDITIONS 33

5.2 AGENCY CONDITIONS 35

5.3 MITIGATION MEASURES 36

6.0 LIMITATIONS OF THIS INITIAL ENVIRONMENTAL EXAM

7.0 REVISIONS

ATTACHMENTS:

Annex 1. Project Climate Risk Management Summary Table 44 Annex 1. Activity Climate Risk Management Summary Table 45

HEALTH PORTFOLIO 2022 – 2027

1.0 PROJECT/ACTIVITY DESCRIPTION

1.1 PURPOSE OF THE IEE

The purpose of this document, in accordance with Title 22, Code of Federal Regulations, Part 216 (22 CFR 216), is to provide a preliminary review of the reasonably foreseeable effects on the environment of the USAID intervention described herein and recommend determinations and, as appropriate, conditions, for these activities. Upon approval, these determinations become affirmed, and specified conditions become mandatory obligations of implementation. This IEE also documents the results of the Climate Risk Management process in accordance with USAID policy (specifically, ADS 201mal).

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

Potential environmental impacts should be addressed through formal environmental mitigation and monitoring plans (EMMPs) and/or Environmental Assessments (EAs), if needed.

1.2 ACTIVITY OVERVIEW

USAID/Kenya's Health Office portfolio is positioned to improve the health outcomes of Kenyans by continuing the implementation of evidence-based interventions to increase access to high-impact HIV/AIDS, tuberculosis, malaria, maternal and child health, family planning, reproductive health, and routine immunization services. Additionally, activities will provide sustainable improvements to governance, supply chain, human resources, financing, and service delivery.

This IEE addresses the following USAID/Kenya Health System Strengthening Office activities:

1. USAID Health Governance and Strategic Partnerships (UHGSP)

2. USAID Health Financing, Analytics and Social Protection Systems for Health

(UHFASPSFH)

AORs/CORs and IPs: How to Use this Development Objective IEE:

For Activities Listed in this IEE:

For each activity in your project and using Table 2, identify the intervention category to which it belongs. NOTE: Intervention categories are generally organized by sector, so if your project contains activities in a single sector, they are likely to be found in only one or two of the intervention categories.

Go to Section 4.1 to find the determination that applies to the intervention category.

Draft and implement an EMMP for each activity that includes the intervention categories associated with your activity that receive a Negative Determination with Conditions.

This EMMP must include the Environmental Impacts identified in Section 3 and expand upon the Mitigation Measures addressed in Section 5.3 The EMMP must also address compliance with all general implementation conditions contained in Section 5.1.

Repeat 1-3 for each activity in your project. If any activity is not included, please consult the MEO.

HEALTH PORTFOLIO 2022 – 2027

3. USAID Private Sector Engagement in Health Service and Systems Strengthening

(UPSEIHSSS)

4. USAID Health Products and Technologies Systems (UHPATS)

5. USAID Human Resources for Health, Quality Management, and Community Health

Systems (UHRFHQMACHS)

6. Afya Ugavi

7. HealthIT

8. Kenya Health Partnerships for Quality Services (KHPQS) includes:

a. USAID 4BetterHealth Activities

b. USAID 4theChild Activities

c. USAID Boresha Jamii ("Improving Communities") Activities

d. USAID Fahari Ya Jamii ("Pride Communities") Activities

e. USAID Imarisha Jamii ("Strengthening Communities") Activities

f. USAID Nuru Ya Mtoto ("Star of the Child") Activities

g. USAID Stawisha Pwani ("Developing the Coast") Activities

h. USAID Tujenge Jamii ("Building Communities") Activities

i. USAID Tujitegemee ("Rely on Ourselves") Activities

j. USAID Tumikia Mtoto ("Serving a Child) Activities

k. USAID Dumisha Afya ("Maintain Health") Activities

l. Ampath Uzima ("Life") Activities

m. USAID Jamii Tekelezi ("Implementing with Communities") Activities

9. Kenya Malaria Vector Control

1.3 ACTIVITY DESCRIPTION

The Intervention Categories analyzed in this document are to be undertaken by USAID/Kenya under the Country Development Cooperation Strategy (CDCS 2020-2025). As a result of the CDCS’ multi-sectoral approach to achieve results in Kenya’s challenging operational environment, the interventions listed within this IEE align with the CDCS.

TABLE 2: DEFINED INTERVENTION AND SUB-INTERVENTION CATEGORIES, AND ILLUSTRATIVE

ACTIONS

Intervention Category

Sub-interventions Illustrative Actions Kenya Mission Activities

Intervention Category 1: Direct Support to Healthcare Worker/Workforce Training;

Strengthening And Development

Sub-intervention 1.1: Provide capacity building to frontline health workers

● Provide training on case management (diagnosis and treatment) to doctors, nurses, laboratory scientists, and other health care and front line workers

● Train pharmacists, data managers, and lab technicians to ensure laboratory quality assurance and performance standards

● Capacity building of social workers, clinical staff, and civil society organizations

● KHPQS

● UHRFHQM

ACHS

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions Kenya Mission Activities

Sub-intervention 1.2: Provide technical assistance and training for health promotion activities

● Mobilize and train support groups to provide community-based and psychosocial support for HIV and TB patients to adhere to treatment

● Train parents and caregivers caring for children with HIV

● Train Community Health Volunteers and Community Health Assistants on various RMNCAH technical modules including WASH to improve maternal, child health and nutrition outcomes.

● Strengthen the connections between health service personnel and communities

● KHPQS

● UHRFHQM

ACHS

Sub-intervention 1.3: Orphans and Vulnerable Children training and support

● Creation and use of ‘’safe spaces’’

● Life skills training

● Entrepreneurship/employment training

● Community service/civic engagement

● Education and health referrals

● KHPQS

Sub-intervention 1.4: Strengthen human resource quality management systems

● Strengthen Human Resource for health management systems

● Improve quality management systems

● UHRFHQM

ACHS

Sub - intervention 1.5: Strengthen Quality of Care for health services

● Strengthen Quality of Care for health services

● Institutionalize Quality of Care for maternal, child health, Nutrition, WASH in health institutions and communities.

KHPQS

Other USAID centrally funded mechanisms

Intervention Category 2: Direct Procurement of Commodities & Strengthening of Commodities, Logistics & Equipment, Non-pharmaceuticals, and Diagnostic Systems

Sub-intervention 2.1: Capacity building to support critical policy and strategy reforms to supply chain management

● Capacity building program for a supply chain professionals' association to advocate for policy reform, monitor and mitigate supply chain risks, and identify and manage fiduciary risk

● UHPATS

● Afya Ugavi

Sub-intervention 2.2: Improve commodity (i.e., pharmaceutical and non-pharmaceutical) and medical equipment procurement and supply chain management strategies to ensure

● Forecast and quantify national commodity needs and procure medicines, medical equipment, non- pharmaceuticals and diagnostics

● Hold workshops in commodities management and assess the performance of supply chains

● Improve supply chain management, strengthen logistics management information systems,

● Afya Ugavi

● UHPATS

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions Kenya Mission Activities availability of health products and support provincial health departments to improve the availability of medicines

● Establish oversight of community transport chains for biological samples from community health facilities to diagnostic sites

● Increase the availability of RMNCAH equipment and develop the capacity of health care workers on the use

Sub-intervention 2.3: Improve the quality of and access to essential health commodities

● Increase access to and appropriate use of essential health commodities, in coordination with supply chain investments

● Increase the availability of quality, affordable contraceptive commodities

● Monitor the availability of contraceptives and undertake scenario planning in anticipation of potential procurement delays

● Support community management and oversight of essential health commodities

● UHPATS

● Afya Ugavi

Intervention Category 3: Direct and Capacity Building Support for Health Service Delivery, Excluding Commodity & Medical Equipment Procurement/ Supply Chain Strengthening

Sub-intervention 3.1: Expand access to and use of malaria, maternal, newborn, and child health, nutrition, and family planning and reproductive health services

● Identify and address care-seeking barriers, including gender-related barriers

● Improve access and quality along the continuum of care for maternal and child health services

● Support the scale-up of high impact health interventions

● UHPATS

● KHPQS

Sub-intervention 3.2: Support the provision of health services delivery

● Provision of ongoing preventative, primary, and limited secondary health-care services delivery for malaria, maternal and child health, nutrition, family planning and reproductive health, and TB

● Increase capacity to plan, implement, and monitor health service delivery at the provincial, zonal, and facility levels

● Provide technical assistance in ongoing monitoring of quality assurance standards and governance-related business operation compliance as it relates to health care service delivery and management

● UHPATS

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions Kenya Mission Activities

Sub-intervention 3.3: Improve TB detection, treatment, and prevention programs

● Support local organizations in implementing locally generated solutions to improve TB diagnosis, treatment, and prevention services

● Strengthen linkages between patients and health services through systematic screening of key populations and implementation of community-based care models

● Build capacity of to effectively lead, plan, manage, coordinate, monitor and evaluate comprehensive TB programs

● UHPATS

● KHPQS

Sub-intervention 3.4: Improve provision of and demand for quality

HIV/AIDS, RMNCAH,

Nutrition and WASH health care services

● Increased HIV testing and treatment access adherence, including enrollment in antiretroviral therapy and support services

● Improve ANC attendance, skilled birth, postnatal care, immunization, Nutrition and WASH services

● Improve and strengthen institutionalization of Infection Prevention and Waste management services

● Strengthen clinical and community Quality of Care for RMNCAH, Nutrition and WASH health services

● Improve identification of patients through health and social service referral systems, including strengthening community-facility referral linkages

● Address TB/HIV co-infection through increased access to testing and TB prevention services

● Improve the efficiency of laboratory functions for more readily accessible diagnostics

● UHPATS

● KHPQS

Intervention Category 4: Social Marketing, Education, & Behavior Change Communication

Sub-intervention 4.1: Support strategic leadership, coordination, and participatory social and behavior change (SBC) interventions

● Implement evidence-based concepts to inform specific behaviors to address, messages, and the appropriate targeted population

4.2: Support

● Focus on community engagement to increase demand for HIV/AIDS, HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions Kenya Mission Activities community and private sector participation in SBC interventions

RMNCAH, Nutrition and WASH services

● Support SBC activities to foster the adoption of healthy behaviors

● Expand communications efforts to include vaccination and countering misinformation

● Improve the quality of information delivered about the importance of childhood vaccinations

Intervention Category 5: Policy and Strategy Development and Assistance

Sub-intervention 5.1: Identify critical policy and strategy reforms to support, excluding supply chain management

● Promote advocacy to advance essential population rights in Kenya

● Address critical gaps in the implementation of HIV and TB national strategies and guidelines

● UHGSP

● UHFASPS

FH

● UPSEIHSS

S

Sub-intervention 5.2: Engage with, and provide technical assistance to the Government of Kenya and other relevant stakeholders

● Support the Government of Kenya in establishing policies that mitigate the HIV-epidemic impact, Maternal and Child health and Nutrition

● Provide programmatic, technical, and operational support and capacity building to the government and civil society organizations

● Capacity building of civil society organizations to monitor the availability of essential medicines and effectively advocate for program improvements

● UHGSP

● UHFASPS

FH

● UPSEIHSS

S

● MCGL

● M-RITE

● Breakthrou gh Action

Intervention Category 6:

Studies, Surveys/ Public Health Surveillance and other Data- Gathering Assessments and Analysis, Models, and Capacity Building in Support of All Areas Above

Sub-intervention 6.1: Conduct public health surveillance activities and studies that include collection of biological samples

● Data collection for monitoring and evaluating HIV/AIDS, TB, and malaria programs

● Provide technical assistance for biomarker data collection

● Strengthen disease diagnosis networks and surveillance systems to improve the detection of multi-and ultra- drug-resistant TB

● Strengthen data collection for monitoring, polio disease surveillance and stool testing for polio diagnosis

● Carry out entomological and epidemiological monitoring to better understand the distribution/behavior of malaria vectors and patterns of insecticide resistance

● KHPQS

● HealthIT

● Afya Ugavi

● PMI Kinga

Malaria

● WHO Polio

● Core Group

Polio

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions Kenya Mission Activities

Sub-intervention 6.2: Strengthen information management systems and quality and use of data for planning and decision making

● Conduct independent impact evaluation (monitoring, evaluation data analysis, and use) to investigate the effectiveness of integrated health project outcomes

● Conduct needs assessments, evaluations, gender analyses, and other information-gathering efforts to inform the design, monitoring, and evaluation of programs

● Development of capacity both in human and institutions at both the national and county levels

● Strengthen quality data, surveillance and monitoring, and evaluation at community levels to refine services and document unmet target needs

● KHPQS

● HealthIT

● PMI

Measure Malaria

6.3: Conduct demographic and health surveys

● Technical assistance to implement demographic and health surveys, including data collection, analysis, and dissemination

● KHPQS

● HealthIT

Intervention Category 7:

Technical Assistance to Malaria Vector Control

Sub-intervention 7.1: Insecticidal- Treated Nets (ITN) and/or Long-lasting Insecticidal Nets Distribution Sub- intervention 7.2: Provide procurement, distribution/delivery, storage, application, and waste disposal associated with World Health Organization Pre- Qualified (WHO/PQ) and/or U.S.

Environmental Protection Agency (USEPA)-approved PMI/Malaria control insecticides, services such as IRS.

● Distribute ITNs through mass campaigns, including continuous distribution in antenatal care and childcare clinics

● Conduct durability monitoring and entomological surveillance to inform decision-making

● Strengthen malaria prevention activities at the community, household, and facility levels, including SBCC on acceptance of vector control interventions, including ITN

● Support for PMI Indoor Residual Spraying (IRS) campaigns

● Afya Ugavi

● PMI

Kinga malaria

● Impact malaria

● Malaria Vector Control

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions Kenya Mission Activities

Intervention Category 8: Small Scale Construction or Rehabilitation of Health Infrastructure (<10,000 sq. ft)

Sub-intervention 8.1: Construction of small-scale facilities and/or limited refurbishment at existing facilities with costing less than $250,00.00 and/or not disturbing an area equal to less than 1,000m2

● Renovations/ Construction of WASH stations and/or facilities

● Support limited rehabilitation and/or expansion of health facilities for WASH, malaria, and supply chain assistance projects

● Refurbishment or construction of IRS waste pits

● KHPQS

● Afya Ugavi

Intervention Category 9:

Resource/ Financial Mobilization

Sub-intervention 9.1: Transfer of resources to promote health strengthening efforts

● Distribute cash transfers to highly vulnerable households

● Provide economic strengthening to orphans and vulnerable children (OVC) and their families

● Conduct economic strengthening of key populations (KPs) and their families

● KHPQS

Sub-intervention 9.2: Improve budgeting and financial management systems

● Creation of a pooled insurance and financing model

Will this project/activity involve construction3 as defined by ADS 201 and 303? Yes ☒ No ☐

3 Construction, as defined by ADS 201 and 303, includes: construction, alteration, or repair (including dredging and excavation) of buildings, structures, or other real property and includes, without limitation, improvements, renovation, alteration and refurbishment. The term includes, without limitation, roads, power plants, buildings, bridges, water treatment facilities, and vertical structures. In the box below, describe any construction planned for this project/activity. Refer to ADS 201maw for required Construction Risk Management procedures.

Renovation and/or cosmetic improvements to health-related facilities (i.e., storerooms, offices, laboratories, healthcare facilities, hospitals HCWM facilities, waste pits, WASH, foundations, etc.). Small scale activities will only involve a total disturbed area equal to or less than 1,000m2. Small scale activities are defined as those involving a total disturbed area equal to or less than 1,000m2

HEALTH PORTFOLIO 2022 – 2027

2.0 BASELINE ENVIRONMENTAL INFORMATION

2.1 LOCATIONS AFFECTED AND ENVIRONMENTAL CONTEXT (ENVIRONMENT, PHYSICAL,

CLIMATE, SOCIAL, THREATENED AND ENDANGERED SPECIES)

Geography. Kenya is located in East Africa, with 536 km of coastline along the Indian Ocean. It shares borders with Ethiopia and Somalia to the north and northeast, South Sudan and Uganda to the west, and Tanzania to the south. The total area of the country is around 580,000 sq km.

Mount Kenya, located in the Kenyan Highlands, is the highest point in the country and the second-highest point in Africa at 5,199 m.

Mount Kenya National Park is also listed as a UNESCO World Heritage Site. Kenya is home to low plains in the east along the Indian Ocean, rising to highlands in the center of the country divided by the Great Rift Valley, a 6,000 km trench running from northern Syria to central Mozambique. A fertile plateau lies to the west of the country. Kenya has a population of almost 45 million people, 3.4 million of which live in the capital city of Nairobi, located in the central highlands.

Mombasa, located on the southeastern coast of Kenya, is the second-largest city by population, at almost 1 million. 4 Climate. Due to its location along the Rift Valley and various other landforms, Kenya’s variable climate brings frequent droughts, floods, and uneven rainfall. The climate in Kenya ranges from tropical along the coast to dry in the interior. Average annual rainfall is about 630 mm, ranging from less than

4 U.S. Central Intelligence Agency World Factbook. Accessed via the Internet 28 July, 2014 at:

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

HEALTH PORTFOLIO 2022 – 2027

200 mm in northern Kenya to 1800 mm on Mt. Kenya.5 Long rains occur from March to June and short rains from October to November. 6 Ecological zones. Kenya has diverse ecological zones and habitats, including lowlands and mountain forests, wooded and open grasslands, semi-arid scrubland, dry woodlands, inland aquatic, and coastal and marine ecosystems. Wetlands are essential in Kenya’s economy, affecting agriculture, livestock production, hydroelectric power, fisheries, and tourism. The marine waters and mangrove areas along the coast are rich in biodiversity and allow locals to fish, although Lake Victoria produces 90% of Kenya’s total catch. Forests are even more significant, supporting agriculture, tourism, and watershed functions. Kenyan forests are also home to some of the highest levels of biodiversity in the country.7 Soil. The soil type in Kenya varies significantly due to topography and variable rainfall. Soils in Western Kenya are mainly acrisols, cambisols, and mixtures and are leached with iron and aluminum oxides. Young nitosol and andosol soils of volcanic origin are located in the central highlands, while coastal soils are generally coarse and low in organic matter and include arenosols, luvisols, and acrisols. Soils in arid and semi-arid areas include vertisols, gleysols, and phaeozems and contain pockets of sodicity and salinity. Soils in these areas are characterized by low fertility and vulnerability to erosion. In the coastal provinces, soil salinity is widespread along the Lake Baringo basin in the Rift Valley and the Tavetta division. 8 Water resources & Irrigation. Kenya is a water-scarce country where demand exceeds renewable freshwater sources. Total renewable water resources totaled 30.7 billion m3/year in

2008.9 Of this total, 30.2 billion m3/year is surface water, and 3.5 billion m3/year is groundwater (most overlap with surface water). Kenya has 9 lakes; most are saline besides Victoria, Naivasha, and Baringo. Additionally, lakes Nakura and Naivasha are designated as Ramsar sites as wetlands of international importance for biodiversity conservation. Kenya has 5 main drainage areas: Lake Victoria, the Rift Valley and inland lakes, Athi River and coast, Tana River, and Ewaso Ng’iro River, the largest, covering 36.3% of the country.10 Hydropower accounts for around 61% of Kenya’s electricity demand at 677.3MW, whereas potential hydroelectric totals 6,000MW. The largest hydropower station is Gitaru, at 225 MW. 11 Agriculture is the largest source of water withdrawal, at 79.2%. Kenya's irrigation potential is estimated at 353,060 ha, with over 50% from the Nile basin (Lake Victoria).12 While 16% of the land has medium to high potential for irrigation, less than 10% is used, totaling only 2% of total arable land. Smallholder and commercial/private schemes dominate irrigation development;

seventy-five percent of Kenya’s agricultural output is produced on small-scale farms. A significant obstacle to the expansion of irrigation is the rising cost of modern irrigation projects.

Due to a lack of investment, the amount of irrigated land in Kenya hasn’t changed for 30 years.

5 Food and Agriculture Organization of the United Nations. Accessed via the Internet 28 July, 2014 at:

http://www.fao.org/nr/water/aquastat/countries regions/kenya/index.stm 6 Water for Agriculture and Energy in Africa: the Challenges of Climate Change Conference. Accessed via the Internet 28 July, 2014 at: http://www.sirtewaterandenergy.org/docs/reports/Kenya-Draft2.pdf 7 Convention on Biological Diversity. Accessed via the Internet 28 July, 2014 at:

http://www.cbd.int/countries/profile/default.shtml?country=ke#facts 8 Food and Agriculture Organization of the United Nations. Accessed via the Internet 28 July, 2014 at:

http://www.fao.org/nr/water/aquastat/countries regions/kenya/index.stm 9 United Nations Environment Programme. Accessed via the Internet 28 July, 2014 at:

http://www.unep.org/dewa/Portals/67/pdf/Kenya.pdf 10 Food and Agriculture Organization of the United Nations. Accessed via the Internet 28 July, 2014 at:

http://www.fao.org/nr/water/aquastat/countries regions/kenya/index.stm 11 Water for Agriculture and Energy in Africa: the Challenges of Climate Change Conference. Accessed via the Internet 28 July, 2014 at: http://www.sirtewaterandenergy.org/docs/reports/Kenya-Draft2.pdf 12 Food and Agriculture Organization of the United Nations. Accessed via the Internet 28 July, 2014 at:

http://www.fao.org/nr/water/aquastat/countries regions/kenya/index.stm

HEALTH PORTFOLIO 2022 – 2027

Consequently, Kenyans depend heavily on rainfed agriculture, contributing to 80% of the nation’s employment. 13 The main irrigated crops are rice, maize, sugarcane, vegetables, bananas, citrus, coffee, tea, cotton, and flowers. 14 Biodiversity. Kenya’s vast biodiversity is due to its long evolutionary history, variable climate, and habitat and ecosystem diversity. The Kenya Wildlife Service (KWS) manages the protected areas in Kenya, home to important biodiversity sites; however, 70% of Kenya’s biodiversity falls outside these protected areas. Kenya hosts five critical hot spots of biodiversity and 61 important bird areas. There are 7000 plants, 25,000 invertebrates, 1,133 birds, 315 mammals, 191 reptiles, 180 freshwater fish, 692 marine and brackish fish, 88 amphibians, and 2,000 species of fungi and bacteria in Kenya. Fourteen of Kenya’s mammalian species are endemic to the country, which is famous for its large mammals like the African elephant, black rhino, leopard, buffalo, and African lion. According to the IUCN report, endangered and threatened species in Kenya include 103 species of bird, 51 mammals, eight amphibians and reptiles, and 26 fish. 15 Climate Change. Kenya’s 2010 National Climate Change Response Strategy (NCCRS) concluded that “evidence of climate change in Kenya is unmistakable.” Notable changes include erratic rainfall, extreme weather events, droughts during the rainy season, and extreme flooding.

Climactic trends reported by the NCCRS include general warming of land locations (besides the coastal zone) and less cold extreme temperatures in the arid and semi-arid lands.16 Climate change is already responsible for melting 11 Mt. Kenya glaciers and the resulting decline in water levels in the Athi and Tana Rivers. Kenya’s significant forests are also at risk, as their distribution is determined by rainfall. Climatic conditions also influence forest fires, which recently damaged the Mount Kenya Forest in early 2012. Local environmental degradation also exacerbates climate change issues. Deforestation, pollution, overgrazing, and habitat loss are significant challenges in Kenya; forest cover has decreased from 12% in the 1960s to just 6% in 2013.

Climate change in Kenya has also had socioeconomic impacts. Prolonged droughts, receding lake levels, and frost in productive agricultural areas, among other impacts, have forced communities to migrate to other areas, leading to conflicts over natural resources. In addition, Kenya’s economy relies heavily on climate-sensitive sectors such as agriculture, tourism, and energy. Kenya depends on rain-fed agriculture for food, meaning pastoral and marginal agricultural areas are especially vulnerable to drought. The tourism industry is based on wildlife populations greatly affected by climate change, while the hydropower sector (contributing to 50% of Kenya’s energy production) is likewise impacted by droughts and erratic rainfall. In general, extreme climatic events could end up costing Kenya’s economy US$500 million/year from factors such as loss of crops and livestock, forest fires, fisheries damage, and reduced hydropower potential. 17 Kenya’s National Climate Change Action Plan 2013-2017 (NCCAP) 18 was developed to implement the NCCRS and help Kenya reach its long-term development goals, including a secure environment. The “low carbon climate-resilient development pathway” outlined in the

13 Irrigation Potential and Investment Return in Kenya. Accessed via the Internet 28 July, 2014 at:

http://www.sciencedirect.com./science/article/pii/S0306919214000712?np=y 14 Water for Agriculture and Energy in Africa: the Challenges of Climate Change Conference. Accessed via the Internet 28 July, 2014 at: http://www.sirtewaterandenergy.org/docs/reports/Kenya-Draft2.pdf 15 Kenya State of the Environment and Outlook 2010, National Environmental Management Authority (NEMA), Kenya 16 The NCCRS notes that a major variable to these observations is urbanization, which could also be an indicator of these observed trends.

17 http://cdkn.org/wp-content/uploads/2013/03/Kenya-National-Climate-Change-Action-Plan.pdf 18 See the full Climate Change Action Plan here: http://cdkn.org/wp-content/uploads/2013/03/Kenya-National-Climate- Change-Action-Plan.pdf

HEALTH PORTFOLIO 2022 – 2027

NCCAP describes strategies Kenya can use to contribute to efforts to reduce greenhouse gas emissions.

2.2 APPLICABLE AND APPROPRIATE PARTNER COUNTRY AND OTHER INTERNATIONAL

STANDARDS (E.G. WHO), ENVIRONMENTAL AND SOCIAL LAWS, POLICIES, AND REGULATIONS

The Kenya Health Office Portfolio may be responsible for waste management and, accordingly, will manage such waste in accordance with the appropriate national standards. However, where national requirements on waste management associated with solid and equipment do not exist, the awardee will select vendors who comply with International Organization for Standardization (ISO) and WHO standards and best practices (e.g., WHO "Safe Management of Wastes from Healthcare Activities"), and the USAID Sector Environmental Guidelines.

A summary of potentially applicable standards, guidelines, and useful references are provided below for developing the EMMP and updating the Kenya Health Office Portfolio integrated WMP. In addition, other references for waste management are identified in Section 4 as specific conditions of the activities."

Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal

● Organization for Economic Cooperation and Development (OECD) Council on the Decision on the control of Transboundary Movements of Wastes

USAID Resources and References

● USAID. Sector Environmental Guidelines o Solid Waste o Healthcare Waste o Healthcare Facilities o Construction

● USAID. Integrated Waste Management Plan

Other International References and Standards

● Safe Management of wastes from health-care activities (Note: Where national requirements on proper waste management do not exist, WHO's "Safe Management of Wastes from Healthcare Activities" handbook is the internationally-recognized standard used by the Bureau for Global Health

2.3 THREATENED AND ENDANGERED SPECIES

The activities proposed include work in already developed areas, clinical settings, and existing infrastructure. Therefore, the activities are not likely to adversely impact threatened and endangered species, or their critical habitat. Activity level actions that include construction or infrastructure improvements should be assessed for the presence of threatened or endangered species, or their critical habitat. Any activity that may adversely impact threatened or

HEALTH PORTFOLIO 2022 – 2027

endangered species or their critical habitat may not proceed without an Environmental Assessment.

2.4 COUNTRY/MINISTRY/MUNICIPALITY ENVIRONMENTAL CAPACITY ANALYSIS (AS

APPROPRIATE)

Kenya’s Environmental Management and Coordination Act (EMCA), established in 1999, provides the legal and institutional framework for environmental management and provisions for environmental protection and conservation. EMCA established the National Environmental Council for environmental policy formulation and national environmental goal-setting, Provincial and District Environment Committees(which are likely to change to County Environmental Committees with devolution) to help decentralize environmental management and enable local communities, a Public Complaints Committee to provide administrative mechanisms for addressing environmental harm, and the National Environment Management Authority (NEMA) as the primary governmental instrument for implementing environmental policies. NEMA has authority for supervision and coordination of all environmental matters and acts as the government's main instrument for the implementation of environmental policies. Kenya is also party to international agreements, including biodiversity, climate change, desertification, endangered species, and hazardous waste.

Kenya’s Environmental Impact Assessment (EIA) regulations require that all projects likely to have a negative environmental impact, or those for which the EMCA requires an EIA, produce an EIA, which must be approved before implementation. Similarly, licensing authorities cannot issue trading, commercial, or development permits or licenses for any projects with likely negative impacts or ECMA EIA requirements that do not have an approved EIA. The EIA act lists projects that must produce an EIA (along with those that are generally likely to have adverse environmental impacts); this list includes urban development projects, projects using water resources, forestry and agriculture activities, processing and manufacturing industry projects, electrical infrastructure projects, fuel management projects, natural conservation area projects, and significant biotechnology developments (including GMO testing). The Act also lays out the EIA process and environmental issues to consider.

The Environmental Management and Coordination Act (EMCA) of 1999 is an Act of Parliament to establish an appropriate legal and institutional framework for the management of the environment. EMCA outlines the rights and responsibilities of all Kenyan citizens in the protection and assurance of a clean and healthy environment. In addition, EMCA guides resources monitoring, access rights, reporting requirements, mitigation, compensation, and restoration activities, and the regulatory and management structures responsible for safeguarding Kenya’s natural resources. This Act created the National Environmental Management Authority (NEMA) as the administrative body tasked with implementing the EMCA 1999.

● Specific regulations outlined by EMCA of importance to this sub-award include:

● Environmental Management and Coordination (Water Quality) Regulations, 2006

● Environmental Management and Coordination (Conservation of Biological Diversity and

Resources, Access to Genetic Resources and Benefit Sharing) Regulations, 2006.

● Environmental Management and Coordination (Waste Management Regulations), 2006

● Environmental Management and Coordination (Wetlands, River Banks, Lake Shores, and Sea Shore Management) Regulation, 2009

● Environmental (Impact Assessment and Audit) Regulations, 2003.

HEALTH PORTFOLIO 2022 – 2027

Kenya’s Environmental Management and Coordination (Water Quality) Regulations were finalized in 2006. These Regulations are to ensure that all-natural water sources are protected.

They apply to drinking water and water used for industrial, agricultural, recreational, and other purposes (http://www.elaw.org/assets/pdf/ke.WaterQualityReg.pdf). This regulation has set standards for the quality of wastewater discharged into the environment, providing the parameters to be regulated in each sector.

In accordance with EMCA, the Minister for Environment and Natural Resources created water quality regulations that define water quality standards for domestic, industrial, agricultural, and recreational use. The regulations set forth measures to prevent water pollution and include standards for the maximum allowable levels of substances in the water to protect drinking water sources. The regulations require NEMA to maintain water quality monitoring records for domestic water sources twice a year. For industrial water use and discharge, standards are defined for maximum allowable limits of substances in the effluent to be discharged into the environment.19[1] http://www.nema.go.ke/images/documents/water quality regulations.pdf

Kenya has a National Health Care Waste Management Plan (2008-2012), and the EMCA has provisions to regulate effluent and hazardous waste. These regulations require that any owner or operator of a trade or industry that discharges effluents, waste, or other pollutants into the environment apply for an effluent discharge and waste disposal license from NEMA. NEMA considers the effects of these pollutants on the quality of water courses and local water requirements before approving licenses.20

In an additional effort to manage the potential risk from HCW, Kenya has made progress with the completion of a short-term National Health Care Waste Management Plan 2008-201221 (Kenya Ministry of Health, undated), long-term National Health Care Waste Management Plan 2006-2015 (World Bank, 2007), National Guidelines on Medical Waste Management, Injection Safety and Medical Waste Management Policy22, the formalization of a National Steering Committee and Working Group on Health Care Waste (HCW) Management, approval of the Environmental Sanitation and Hygiene Policy,23 and formation of an Inter-Sectoral Working Group on health care waste management.24

EMCA outlines a process for which air quality standards should be developed. The Standards and Enforcement Review Committee is responsible for advising NEMA on establishing criteria and procedures for measuring air quality, which is currently in draft form.25 This includes ambient, occupational, and emission standards for various sources and criteria for reducing existing sources of air pollution and greenhouse gases. Owners of operators of trades that emit substances likely to cause air pollution must apply for a license from NEMA, which will consider the effect of emission on air quality and require the applicant to submit an EIA, as necessary. 26

19[1] See complete water quality regulations here:

http://www.nema.go.ke/images/documents/water quality regulations.pdf 20 ibid 21 Available online at:

http://nascop.or.ke/library/PEP/National%20Health%20Care%20Waste%20Management%20Plan%20for%20Kenya %202008-2012%20a.pdf\ 22 Available online at: http://www.path.org/files/Kenya-NationalPolicyoninjection.pdf.

23 Available online at: http://docs.watsan.net/Scanned PDF Files/Class Code 8 Countries/824-KE07-19289.pdf.

24 Paragraph pulled directly from Health Care Waste Management Costing Analyst for USG-Supported Health Care Facilities in Kenya, April 2014 25 http://www.nema.go.ke/index.php?option=com content&view=article&id=141&Itemid=493 26 Kenya Environmental Management and Coordination Act, 1999

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3.0 ANALYSIS OF POTENTIAL ENVIRONMENTAL RISK

As set out in section 1.3, for the purpose of environmental review, current and anticipated activities in the USAID/Kenya Health System Strengthening Office portfolio are grouped into the following intervention categories:

Intervention Category 1 Direct Support to Healthcare Worker/Workforce Training;

Strengthening & Development

Intervention Category 2 Direct Procurement of Commodities & Strengthening of Commodities, Logistics & Equipment, Non-pharmaceuticals and Diagnostic Systems

Intervention Category 3 Direct and Capacity Building Support for Health Service Delivery, Excluding Commodity Procurement/ Supply Chain Strengthening

Intervention Category 4. Social Marketing, Education, & Behavior Change Communication Intervention Category 5. Policy and Strategy Development and Assistance Intervention Category 6. Studies, Surveys/ Public Health Surveillance and other Data-

Gathering Assessments and Analysis, Models, and Capacity Building in Support of All Areas Above

Intervention Category 7. Technical Assistance to Malaria Vector Control Intervention Category 8. Small Scale Construction or Rehabilitation of Health Infrastructure

(<10,000 sq. ft) Intervention Category 9. Resource/ Financial Mobilization

Each category contains several entailed activities. In section 3.2, the entailed activities are described, and their potential impacts analyzed. On this basis, Recommended Determinations are made. In many cases, Negative Determinations entail conditions. Upon approval of his IEE, implementation of these conditions becomes mandatory.

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

MANAGE RESULTING WASTES

This section is a general discussion and analysis of waste-related impacts of health care activities. It is referenced at several points in the analyses of the specific interventions categories that follow in section 3.2. It supports this subsequent analysis; no recommended determinations are attached specifically to this section.

Although healthcare activities provide many important benefits to communities, they can also unintentionally do harm via poor management of the wastes they generate. These wastes generally fall into two major categories in terms of public health risk and recommended methods of disposal.27

● Non-Hazardous or 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 percent of waste generated by

27 World Health Organization (WHO). 2014. “Safe management of wastes from health-care activities”.

https://apps.who.int/iris/bitstream/handle/10665/85349/9789241548564 eng.pdf?sequence=1

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healthcare facilities falls into this category, and it can be burned, with subsequent proper ash management, or taken to the landfill without any additional treatment.

● Hazardous healthcare wastes make up the remaining 10-25 percent of healthcare facility waste. Hazardous waste must be specially managed and disposed of to prevent adverse impacts on human health and the environment. Hazardous healthcare waste includes a variety of streams or types including sharps, rapids test kits, infectious waste, pathological waste, pharmaceutical waste, cytotoxic waste, chemical waste, and radioactive waste. All blood and bodily fluids are potentially infectious.

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

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

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

Additional health risks related to disposal include burning pharmaceuticals and plastic medical supplies (including new or used condoms) at low temperatures or in open containers, which results in the 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 public.28

Potentially infectious wastes: Improper training, handling, storage, and disposal of the waste generated in health care facilities or activities can spread disease through several mechanisms.

Transmission of disease through infectious waste is the greatest and most immediate threat from healthcare waste. If waste is not treated in a way that destroys the pathogenic organisms, dangerous quantities of microscopic disease-causing agents—viruses, bacteria, parasites, or fungi—will be present in the waste. These agents can enter the body through punctures and other breaks in the skin, mucus 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 abuses, 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 abuses, and others who handle sharps have become infected with HIV and/or hepatitis B and C viruses through pricks or reuse of syringes/needles.

28 USAID. 2019. “Sector Environmental Guidelines – Healthcare Waste”.

https://www.usaid.gov/sites/default/files/documents/1864/FINAL HCW SEG 508 12.02.19.pdf

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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.29

3.2 POTENTIAL ENVIRONMENTAL AND SOCIAL IMPACTS PER INTERVENTION CATEGORY

INTERVENTION CATEGORY 1: Direct Support to Healthcare Worker/Workforce Training;

Strengthening & Development

TABLE 3A. POTENTIAL IMPACTS – CATEGORY 1

Sub-intervention Potential environmental and social impacts Sub-intervention 1.1: Provide capacity building to frontline health workers and the community

Environmental Impacts

● Capacity building and training interventions are likely to have negligible foreseeable direct impacts on the environment. However, in cases where training involves the generation of wastes (e.g., blood sampling, swabs, cultures), it could result in disease transmission and, if not properly contained, lead to negative impacts on water quality and community health.

Social Impacts

● While training is expected to support significant public health benefits, this intervention could exacerbate inequities in health service access if issues related to gender equity or the needs of vulnerable populations are not considered in the development of training materials or during training exercises.

● Training materials must also consider the health and safety of healthcare workers involved in handling hazardous wastes, as this oversight can lead to increased occupational hazards.

Sub-intervention 1.2: Provide technical assistance and training for health promotion activities

Sub-intervention 1.3: Orphans and Vulnerable Children training and support

Negligible adverse environmental or social impacts are associated with this sub-intervention.

Sub-intervention 1.4: Strengthen human resource quality management systems

Negligible adverse environmental or social impacts are associated with this sub-intervention.

INTERVENTION CATEGORY 2: Direct Procurement of Commodities & Strengthening of Commodities, Logistics & Equipment, Non-pharmaceuticals and Diagnostic Systems

TABLE 3B. POTENTIAL IMPACTS – CATEGORY 2

Sub-intervention Potential environmental and social impacts Sub-intervention 2.1: Capacity building to support critical policy and strategy reforms to supply chain management

Environmental Impacts

● In-country supply chains result in increased procurement, use, and disposal of healthcare commodities and supplies.

Sub-intervention 2.2: Improve commodity (i.e., pharmaceutical

29 USAID. 2019. “Sector Environmental Guidelines – Healthcare Waste”.

https://www.usaid.gov/sites/default/files/documents/1864/FINAL HCW SEG 508 12.02.19.pdf

HEALTH PORTFOLIO 2022 – 2027

and non-pharmaceutical) and medical equipment procurement and supply chain management strategies to ensure availability of health products

● Many procured commodities inevitably end up as waste (e.g., test kits, etc.), generate waste as a consequence of their use (e.g., vaccines, pharmaceuticals), or have the potential to end up as waste due to spoilage or expiration (i.e., all pharmaceuticals). Improper disposal of potentially infectious and pharmaceutical wastes has potentially significant adverse impacts, as discussed in section 3.1.

Sub-intervention 2.3: Improve the quality of and access to essential health commodities

INTERVENTION CATEGORY 3: DIRECT AND CAPACITY BUILDING SUPPORT FOR HEALTH

SERVICE DELIVERY, EXCLUDING COMMODITY PROCUREMENT/ SUPPLY CHAIN

STRENGTHENING

TABLE 3C. POTENTIAL IMPACTS – CATEGORY 3

Sub-intervention Potential environmental and social impacts Sub-intervention 3.1: Expand access to and use of malaria, maternal, newborn, and child health, nutrition, and family planning and reproductive health services

Environmental Impacts

● While improved healthcare service delivery and systems strengthening is expected to support the achievement of significant public health benefits, they will also result in increased generation of healthcare waste (e.g., blood samples, sharps, and medicines).

● While increased uptake of detection, testing, and treatment…