Attachment 6 - Initial Environmental Examination (IEE).pdf

Asia Bureau

INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ACTIVITY DATA

Country Code: 306 Program Area: Health and Nutrition Assistance Objective: SO3: IMPROVE HEALTH OUTCOMES FOR

WOMEN AND CHILDREN

Intermediate Results: IR 3.1: Improve Access to and Quality of Health Care

IR 1.1: Strengthen Capacity of Local Organizations Country or Region: Afghanistan Activity Name: Integrated Health Initiative (IHI) Activity Funding Period: May 1, 2025 to April 30, 2030 Life of Project (LOP) Amount: $92,500,000 IEE Prepared by: Ghulam Shams Bigana Date: July 30, 2024 IEE Amendment (Y/N): N

ENVIRONMENTAL ACTION RECOMMENDED:

Categorical Exclusion [ X] Deferral [ ]

Positive Determination [ ] Negative Determination [ ]

Negative Determination With Conditions

[X] Exemption [ ]

Climate Change Vulnerability Risk None [ ] Low [ ] Medium [X ] High [ ]

PURPOSE, BACKGROUND AND ACTIVITY DESCRIPTION

1.1. Purpose and Background

The purpose of this IEE is to provide threshold determinations for the proposed Integrated Health Initiative (IHI) activities to increase equitable access to and use of quality health services, and increase adoption of healthy behaviors, especially for women and children, in USAID target areas.

The IEE provides a brief statement of the factual basis for the Threshold Decision whether an Environmental Assessment or an Environmental Impact Statement is required for the subject activity.

USAID/Afghanistan formalized current practices and procedures regarding compliance with the Office of Foreign Assistance Control (OFAC) licensing requirements, and the main concern of the OFAC sanctions is the transfer of funds to sanctioned entities and persons. IHI is an off-budget assistance program, and the direct beneficiaries will be men, women, and children in the urban population. Therefore, based on the developmental context in which the IHI implementing organization will be operating, OSS has no reasonable basis to believe that sanctioned groups or individuals will benefit from the IHI award in violation of U.S. law.

1.2. Activity Description

The Integrated Health Initiative is designed to serve five high-density population provinces - Kabul, Kandahar, Nangarhar, Herat, and Balkh - with a total population of 12.2 million, which is approximately 25 percent of the total population of Afghanistan. These five provinces have high disease burden and vulnerable populations, and access to health services is limited due to distance, high costs, low awareness, and a shortage of female health care providers. The Activity will increase equitable access to and use of quality health and nutrition services, and increase adoption of healthy behaviors, especially for women and children, in USAID target areas. The Activity’s priority health areas are maternal and newborn health; family planning and reproductive health; child health; nutrition; tuberculosis (TB); and mental health. This Activity will build on prior USAID investments, particularly the Assistance to Families and Indigent Afghans to Thrive (AFIAT) Activity, The Urban Health Initiative (UHI), and the Local Health System Sustainability (LHSS) Activity.

The overall goal of the IHI Activity is to improve health outcomes for women and children.

The purpose is to increase equitable access to and utilization of quality health and nutrition services and adoption of healthy behaviors, especially for women and children in USAID target areas. This will be achieved through three objectives:

Objective 1: Increase Equitable Access to Health and Nutrition Services

Objective 2: Improve the Quality of Health Services

Objective 3: Healthy Behaviors and Health Seeking Practices Improved

Activities under the program objectives are the following:

Program Objective 1: Increase Equitable Access to Health and Nutrition Services

1. Adapt and expand a core set of proven high impact maternal, neonatal and child health (MNCH), FP/RH, nutrition, MHPSS, and TB interventions, including self-care (e.g. home-based practices) as needed.

2. Adapt and expand innovative approaches to reduce gender, cultural, age-related and other barriers to access basic health and nutrition services and products.

3. Support implementation of affordable primary health care packages in private hospitals.

4. Strengthen market development approaches to increase availability of priority products, including contraceptives (including long-acting reversible contraception) with linkages between social marketing, public, and private sectors.

5. Strengthen implementation of light-touch social franchising models to promote quality essential products and improve priority interventions and referral systems, using the network of CHWs and midwives.

6. Strengthen community-to-facility referral systems, including transportation, emergency calls, and follow-ups in urban and rural areas, including in the private sector.

Program Objective 2: Improve the Quality of Health Services

1. Implement and expand quality improvement standards in public and private health facilities and communities to improve healthcare services.

2. Improve clinical and non-clinical capacity of healthcare providers (e.g doctors, midwives, nurses, psychosocial and nutrition counselors, and CHWs) to deliver quality health services and counseling, including technical capacity of professional associations to serve as champions.

3. Support client-driven programs and interventions to seek feedback from communities to understand their needs and desires, and strengthen priority health services.

4. Strengthen supportive supervision and mentoring.

5. Strengthen maternal and perinatal death surveillance and response and integration of data reporting into DHIS2, including stillbirth data.

6. Support and enable private sector health facilities to regularly report on their health service data.

7. Work with the private sector to improve the use of quality data for decision- making.

Program Objective 3: Healthy Behaviors and Health Seeking Practices Improved

1. Review and modify existing health messages and select context appropriate health messages.

2. Promote and support the use of telecommunication technology, mass media, and mobile messaging to increase awareness and reach more women and girls, particularly those with low literacy and in rural areas.

3. Engage communities in a constructive dialogue to improve health seeking behaviors and give a prominent role to religious and community elders to enforce/promote health seeking behaviors.

4. Work with NGOs and the private sector to establish/strengthen their current community based programs and establish health camps to promote health care and improve referrals, including for MHPSS.

5. Support increased male engagement in counseling sessions in health facilities to improve healthy practices and decision-making.

6. Train health providers, CHWs, and community members to implement community engagement activities to improve healthcare and social accountability.

2.0 COUNTRY AND ENVIRONMENTAL INFORMATION

2.1 Locations Affected

The IHI Activity will focus on five high-density population provinces - Kabul, Kandahar, Nangarhar, Herat, and Balkh - with a total population of 12.2 million, which is approximately 25 percent of the total population of the country. These five provinces have high disease burden and vulnerable populations, and access to health services is limited due to distance, high costs, low awareness, and a shortage of female health care providers. Moreover, Kandahar, Herat and Nangarhar have recently received large numbers of Afghans returning from neighboring countries. These populations settle in the urban areas for long periods of time before they go to their native provinces, resulting in an added burden to the health care sector.

2.2 Socio-economic baseline

Afghanistan is a landlocked country located in Central Asia, north and west of Pakistan, and east of Iran. Political change in August 2021 that resulted in the takeover of the country by the Taliban brought about tremendous changes in the lives of Afghans. Women and girls – half of the country’s 40 million people – have been dispossessed of basic rights and freedoms, including restrictions on women’s education above the grade of 6, employment, and their participation in public life. The massive collapse of the economy immediately after the takeover, combined with the adverse effects of an unusually severe drought, have accelerated Afghanistan’s decade-long slide into poverty, and turned it into one of the poorest countries in the world.

As reported by the UNDP in 2023, the economy contracted by 20.7 percent in 2021, followed by a further contraction of 3.6 percent in 20221. Considering a population growth rate around two percent, per capita income is estimated to have fallen by a staggering 30 percent between 2020 and 2022. Recent indicators suggest a degree of economic stabilization, a more stable exchange rate, and more muted inflation, but relative stabilization has happened at a significantly lower level of economic activity. With limited coping mechanisms available, impoverished Afghans have had to reduce consumption (including food), borrow heavily, beg, and take extreme measures to survive. The situation has also further increased child labor and child marriage.

Despite the health sector progress made in the two decades before August 2021, Afghanistan faces critical health problems, especially for women and children. Maternal mortality, the highest in the world, is caused by obstetric hemorrhage (27 percent), infections (22 percent), and abortion (7 percent) (Afghanistan Health Survey (AHS), 2018). Afghanistan’s contraceptive prevalence rate remains one of the lowest in the world, with 17.4 percent of married women using a modern method (AHS, 2018).

The newborn mortality rate is 34 deaths per 1,000 live births (UN Child Mortality Estimate, 2021). The leading causes of death in children under-five are sepsis/meningitis (19.9 percent), preterm birth complications (19.8 percent), and pneumonia (17.2 percent).

Infections accounted for over 62.8 percent of all deaths among children under five years old (AHS, 2018). Childhood illness is exacerbated by very low vaccination coverage - only 36.6 percent of children 12-23 months old have received all basic immunizations (MICS, 2023), and the number of acute malnutrition cases is increasing (UNICEF Nutrition Report, 2023).

The Taliban does not support polio campaigns and restricts vaccinators’ home-to-home visits to vaccinate children, instead proposing an ineffective site-to-site visits’ approach. This has increased children missing polio vaccines and resulted in active cases going up to 19 compared to 3 cases in 2023.

2.3 Policy, Legal and Regulatory Framework and International Conventions

The primary relevant laws and legislations framing social and environmental issues are: the Environment Law of Afghanistan (2007), the Land Expropriation Law (2005), the Water Law

1 https://www.undp.org/afghanistan/press-releases/undp-warns-restrictions-on-womens-rights-will-worsen-economic-catastrophe-afghanistan https://www.undp.org/afghanistan/press-releases/undp-warns-restrictions-on-womens-rights-will-worsen-economic-catastrophe-afghanistan

(2004), and the Law on the Preservation of Afghanistan’s Historical and Cultural Heritages (2004).

Afghanistan is a party to international agreements on Biodiversity, Climate Change, Desertification, Endangered Species, Environmental Modification, Marine Dumping, and Ozone Layer Depletion. The country also signed the Minamata Convention on Mercury which was recently ratified2.

Health Sector Transition Strategy (2023-2025) The Health Sector Transition Strategy (HSTS) is a product of the Health Sector Thematic Working Group (H-STWG). At the request of the H-STWG co-chairs from WHO, USAID, and the World Bank, the document was compiled by penholders from the Global Financing Facility, WHO, and UNICEF.

National Health Policy (2015-2020) Basic health and essential hospital services are respectively delivered through the Basic Package of Health Services (BPHS) and Essential Package of Hospital Services (EPHS). The contents of both packages are evidence-based, cost-effective interventions and are free of financial cost to all. Specialist (tertiary) care will be provided for a fee through public-private investment and other partnerships and will be made accessible to the poor. It is a policy priority of the Ministry of Health (MoPH) to ensure the provision of quality pharmaceuticals and other health commodities through a well-regulated quality control body.

Infection Prevention and Control Policy, 2005 The MOPH's National Policy on Infection Prevention and Control for Hospitals and Health Centers (2005) provides the broad principles of infection prevention and control (IPC) for all Afghanistan healthcare facilities. The procedures manual provides specific guidelines for implementation of effective IPC programs in hospitals and health centers.

Public Health Law The Afghanistan Public Health Law is legislated based on the orders mentioned in articles 52, 53, and 54 of the constitution, for the control and treatment of diseases and provision of free health services, ensuring and expanding health services and private health centers, execution of effective health services in different locations, including offering appropriate control and treatment services, improvement of individual health and environment, prevention and control of contagious diseases, support for maternal and child health, and provision of appropriate health conditions in workplaces of production and service organizations.

Drug Law The Drug Law is legislated based on the order in article 29 of the Afghanistan Public Health Law, for the organization and management of the selection, production, importation, distribution, storage, and appropriate use of medicine and medical equipment in Afghanistan.

MoPH is authorized to issue permits to production and importing agencies, general stores and drug stores for production, importation and sales of medicines and other medical equipment in Afghanistan.

2 https://minamataconvention.org/en/parties/afg https://minamataconvention.org/en/parties/afg

National Policy for Waste Management and Safe Disposal of Pharmaceutical Products, 20165 This policy deals with the safe disposal of expired pharmaceutical commodities.

Regulation on Protection of Health Workers at Risk, 2015 [Persian] This Regulation implements Article 66 of the Labor Code. It aims to 1) deliver better health services; 2) provide a suitable and safe work environment for health workers; 3) provide support for health workers; and 4) determine the size of employee health benefits.

Climate change and extreme weather events have a devastating impact on human health. It is increasingly affecting health in Afghanistan, a country already facing significant socio-political and economic challenges. The increased incidence of higher temperature, drought, extreme rainfall and floods, will increase risks of diseases such as vector-borne and water borne in Afghanistan (WB and ADB, 2021)3. Afghanistan is one of the highly rated of under-five diarrheal deaths globally, and the risks associated with the disease prevalence will likely increase as the incidence of climate change-related extreme weather events such as floods and droughts increases. These events will reduce people's ability to work and earn a livelihood. It is considered an important factor contributing to increased mortality and morbidity4. Kabul is one of the populated provinces of Afghanistan and climate change has affected the health of millions of people by increasing their vulnerability to infectious diseases, respiratory problems and other health conditions.

2.3.1 ENVIRONMENTAL FRAMEWORK

All information included below references environmental policies, strategies, laws, regulations, and agreements under the pre-August 2021 Government of the Islamic Republic of Afghanistan.

The former Islamic Republic of Afghanistan (Afghanistan) was one of the lowest emitters of greenhouse gasses (GHGs) worldwide, but Afghanistan is one of the most vulnerable to climate disasters. Afghanistan ranks sixth among countries most vulnerable to climate change5, and is categorized in the INFORM Climate Change Risk Index (2022) as very high risk6. Drought affects more than 50% of the population, causing desertification, soil degradation, and migration of wildlife.7 Beyond climate-related impacts, the country faces environmental problems related to deforestation, uncontrolled urbanization, solid waste disposal, air and water pollution, depletion of groundwater resources, and limited renewable energy alternatives.

Afghanistan’s environmental framework is relatively robust, with national strategies and policies focused on various sectors. The framework Environment Law covers management of various activities affecting the environment. Despite this, insecurity and poor infrastructure

7 https://www.unocha.org/news/afghanistan-alarming-effects-climate-change

6https://drmkc.jrc.ec.europa.eu/inform-index/Portals/0/InfoRM/2024/INFORM%20Annual%20Report%202024.

pdf

5 https://www.undp.org/afghanistan/blog/afghanistan-brink-climate-catastrophe-we-must-act-now

4 Masood, W., Aquil, S., Nadeem, A., Mehmood, H., Islam, Z., Essar, M. Y., & Ahmad, S. (2022). Impact of climate change on health in Afghanistan amidst a humanitarian crisis. The Journal of Climate Change and Health, 6, 100139.

3https://documents1.worldbank.org/curated/en/284301491559464423/pdf/114097-WP-P155025-PUBLIC-afgha nistan-low.pdf https://faolex.fao.org/docs/pdf/afg185430.pdf https://www.unocha.org/news/afghanistan-alarming-effects-climate-change https://drmkc.jrc.ec.europa.eu/inform-index/Portals/0/InfoRM/2024/INFORM%20Annual%20Report%202024.pdf https://drmkc.jrc.ec.europa.eu/inform-index/Portals/0/InfoRM/2024/INFORM%20Annual%20Report%202024.pdf https://www.undp.org/afghanistan/blog/afghanistan-brink-climate-catastrophe-we-must-act-now throughout the country exacerbate environmental and climate change challenges.8 The National Environmental Protection Agency (NEPA) is the authority responsible for developing and implementing laws, strategies, and policies to conserve and rehabilitate the environment. NEPA focuses its efforts on climate change, air pollution, noise pollution, water quality, waste management, and sustainable development.

Environment Law, 20079 This framework law covers management of various activities affecting the environment;

integrated pollution control; water resource conservation and management; biodiversity and natural resources conservation and management; environmental education and training; and compliance and enforcement. The objectives of the law are to 1) protect the health of humans, flora, and fauna; 2) maintain ecological functions and evolutionary processes; 3) preserve the environment for future generations; 4) conserve natural and cultural heritage;

and 5) encourage sustainable development of the national economy. The Law establishes the National Environmental Protection Agency (NEPA) and outlines provisions for conducting environmental impact assessments, obtaining pollution control licenses, managing and protecting water resources, protecting national biodiversity, restoring indigenous vegetation, and managing rangelands.

2.3.2 National Climate Change Frameworks

Afghanistan’s Intended Nationally Determined Contribution (INDC), 201510 Afghanistan’s INDC aims to enhance the adaptive capacity and resilience of Afghanistan’s agricultural sector, environment, and population to climate change. It seeks to develop and implement Low Emission Development Strategies (LEDS) and efficiently mainstream climate change considerations into national policies, strategies, and plans. Adaptation measures focus on 1) monitoring and assessing vulnerability and adaptation to climate change; 2) mainstreaming climate change adaptation technologies into sectoral policies; 3) coordinating adaptation technology transfer; 4) expanding the meteorological and hydrological monitoring network; 5) developing water resources; and 6) sustainably using natural resources. Mitigation measures focus on reducing GHG emissions in the energy, forest and rangeland, industrial process, agriculture and livestock, and waste management sectors.

Table 1. Selected data for Afghanistan

Socioeconomic data

10 https://faolex.fao.org/docs/pdf/afg190111.pdf

9https://faolex.fao.org/docs/pdf/afg185430.pdf 8https://www.unep.org/resources/report/reporting-state-environment-afghanistan https://www.nepa.gov.af/indexen https://www.nepa.gov.af/indexen https://faolex.fao.org/docs/pdf/afg185430.pdf https://faolex.fao.org/docs/pdf/afg190111.pdf https://faolex.fao.org/docs/pdf/afg190111.pdf https://faolex.fao.org/docs/pdf/afg185430.pdf https://www.unep.org/resources/report/reporting-state-environment-afghanistan

Total Population- 31.6 million (2018-19)11 Population Growth Rate (annual %)- 2.34 Urban Population (23.7 % of total)- 7.5 million Life Expectancy (years)- 65.2 Infant Mortality Rate (per 1,000 live births)- 112.8 GDP (current $)- 20.2 billion (2017-18) GDP breakdown: Agriculture 22.6 %, Industry 22.4 % (2015) Services- 50.7 % ( 2017-18) GDP Growth (annual %)- 2.9 ( 2017-18) Inflation (annual %) -4.4% (2017-18)12 Unemployment Rate (annual %)- 35 Population Density- 42 persons/km2 (in 2017-18) Electricity Consumption - 2.226 billion kWh (2009 est.)

NHPP Generation Capacity - 100 MW13

Installed Capacity - 25 M

3.0 RECOMMENDED THRESHOLD DECISIONS AND MITIGATION ACTIONS

Below are the recommended actions for the activities described above, their impacts on the environment and recommended Threshold Determinations and Conditions, if any:

Activity Effects on natural or physical environmen t

Recommended Threshold Determination

Program Objective 1:

1. Adapt and expand innovative approaches to reduce gender, cultural, age-related and other barriers to access basic health and nutrition services and products.

2. Strengthen community-to-facility referral systems, including transportation, emergency calls, and follow-ups in urban and rural areas, including in the private sector.

Program Objective 2:

1. Support client-driven programs and interventions to seek feedback from communities to understand their needs and desires, and strengthen priority health services.

2. Strengthen supportive supervision and mentoring.

3. Support and enable private sector health facilities to regularly report on their health service data.

No effect on the natural or physical environment

Categorical Exclusions, no action required per 22 CFR 216.2(c)(2)(i), (iii), (v) and (xiv)

13https://www.worldbank.org/en/news/feature/2018/05/14/largest-plant-restarts-operations-in-first-step-developi ng-afghanistan-hydropower

12https://www.worldbank.org/en/news/feature/2018/05/14/largest-plant-restarts-operations-in-first-step-developi ng-afghanistan-hydropower

11Afghanistan Statistical Yearbook 2017-18, National Statistics and Information Authority https://www.worldbank.org/en/news/feature/2018/05/14/largest-plant-restarts-operations-in-first-step-developing-afghanistan-hydropower https://www.worldbank.org/en/news/feature/2018/05/14/largest-plant-restarts-operations-in-first-step-developing-afghanistan-hydropower https://www.worldbank.org/en/news/feature/2018/05/14/largest-plant-restarts-operations-in-first-step-developing-afghanistan-hydropower https://www.worldbank.org/en/news/feature/2018/05/14/largest-plant-restarts-operations-in-first-step-developing-afghanistan-hydropower

4. Work with public and private sectors to improve the use of quality data for decision-making.

Program Objective 3:

1. Review and modify existing health messages and select context appropriate health messages.

2. Engage communities in a constructive dialogue to improve health seeking behaviors and give a prominent role to religious and community elders to enforce/promote health seeking behaviors.

3. Support increased male engagement in counseling sessions in health facilities to improve healthy practices and decision-making.

List the activities that have an impact

Objective 1:

1. Adapt and expand a core set of proven high impact maternal, neonatal and child health (MNCH), FP/RH, nutrition, MHPSS and TB interventions, including self-care (e.g.

home-based practices) as needed.

2. Support implementation of affordable primary health care packages in private hospitals.

3. Strengthen implementation of light-touch social franchising models to promote quality essential products and improve priority interventions and referral systems, using the network of CHWs and midwives.

4. Adapt and expand innovative approaches to reduce gender, cultural, age-related and other barriers to access basic health and nutrition services and products.

5. Strengthen market development approaches to increase availability of priority products, including contraceptives (including long-acting reversible contraception) with linkages between social marketing, public and private sectors.

Objective 2:

1. Implement and expand quality improvement standards in public and private health facilities and communities to improve healthcare services.

2. Improve clinical and non-clinical capacity of healthcare providers (e.g doctors, midwives, nurses, psychosocial and nutrition counselors, and CHWs) to deliver quality health services and counseling, including technical capacity of

Limited environmental and social impact if Conditions adhered to

Negative Determination with Conditions per 22 CFR 216.3

Conditions:

Technical training shall consider international standards and best practices as stipulated in USAID sector environmental guidelines.

Medical waste shall be handled in accordance with WHO standards as stipulated in USAID sector environmental guidelines14.

Only high-quality equipment and products shall be procured from a reputable and certified vendor.

These products shall be used in accordance with the manufacturer specifications.

Expired products shall be disposed of in accordance with international best practices.

Medical waste management guideline can be found in USAID sector environmental guidelines15.

For procurement and use of disinfectant, IP shall adhere to the 2024 USAID/Afghanistan

PERSUAP.

For rehabilitation:

15https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environ mental-guidelines-resources

14https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environ mental-guidelines-resources https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environmental-guidelines-resources https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environmental-guidelines-resources professional associations to serve as champions.

3. Strengthen maternal and perinatal death surveillance and response and integration of data reporting into DHIS2, including stillbirth data.

Objective 3:

1. Promote and support the use of telecommunication technology, mass media, and mobile messaging to increase awareness and reach more women and girls, particularly those with low literacy and in rural areas.

2. Work with NGOs and the private sector to establish/strengthen their current community based programs and establish health camps to promote health care and improve referrals, including for MHPSS.

3. Train health providers, CHWs and community members to implement community engagement activities to improve health seeking behaviors.

The implementing partner shall make sure that all rehabilitation activities are performed in an environmentally sound manner and according to international best practices.

All applicable safety standards shall be adhered to in rehabilitation and construction activities including use of appropriate Personal Protective Equipment (PPE).

Table 1. Proposed activities and recommended threshold decisions for the Integrated Health Initiative program.

4.0 ENVIRONMENTAL RECOMMENDATIONS

Recommended Action: Categorical Exclusions (ca. 90% of funding)

The Integrated Health Initiative activities that do not have an effect on the natural and physical environment fit within the categories listed in 22 CFR 216.2 (c)(2) and are categorically excluded from any further environmental review requirements. The originator of the proposed action has determined that the proposed activities are within the following classes of actions:

● Education, technical assistance, or training programs, except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.). [22 CFR 216.2(c)(2)(i)];

● Analyses, studies, academic or research workshops and meetings. [22 CFR 216.2(c)(2)(iii)];

● Document and information transfers. [22 CFR 216.2(c)(2)(v)]; and

● Studies, projects or programs intended to develop the capability of recipient countries to engage in development planning, except to the extent designed to result in activities directly affecting the environment (such as construction of facilities, etc.). [22 CFR 216.2(c)(2)(xiv)].

Recommended Action: Negative Determination with Conditions (ca. 10 % of funding)

● Technical training shall consider international standards and best practices as stipulated in USAID sector environmental guidelines16.

● Medical waste shall be handled in accordance with WHO standards as stipulated in USAID sector environmental guidelines.

● Only high-quality equipment and products shall be procured from a reputable and certified vendor. These products shall be used in accordance with the manufacturer specifications.

● Expired products shall be disposed of in accordance with international best practices.

Medical waste management guideline can be found in USAID sector environmental guidelines17.

● For procurement and use of disinfectant, IP shall adhere to the 2024 USAID/Afghanistan PERSUAP18.

● For rehabilitation:

The implementing partner shall make sure that all rehabilitation activities are performed in an environmentally sound manner and according to international best practices.

● All applicable safety standards shall be adhered to in rehabilitation and construction activities including use of appropriate Personal Protective Equipment (PPE).

5.0 CLIMATE CHANGE RISK SCREENING

Afghanistan is extremely vulnerable to the impacts from global climate change. Available information suggests that since 1960, the annual temperature has increased 0.6°C and is expected to rise even more, and there is an increase in the frequency of extreme weather events such as droughts and rainstorms which may affect water availability19. With projected economic and population growth, Afghanistan’s water storage limitations and reliance on snowmelt and transboundary watersheds create significant climate change vulnerability. To minimize the negative impacts of climate change, USAID is required by ADS201mal20 to incorporate climate change risk screening for all new projects as of October 1, 2016. Climate risk screening will help the activities under the Integrated Health Initiative components to adjust its activities to better adapt to climate change and maximize results.

Annex 1 shows the Climate Risk Management screening for the Integrated Health Initiative activity which has been completed by the OSS technical staff, including the MEO and Climate Integration Lead.

The climate risk screening conducted summarizes the climate change vulnerability risk as Moderate for the Integrated Health Initiative activity.

The following climate change risk management requirements apply:

● Increase medical training to improve awareness and treatment of climate-related health issues.

● Improve strategic planning for health services to account for climate change.

20 https://www.usaid.gov/sites/default/files/2022-12/201mal.pdf 19 https://www.climatelinks.org/resources/climate-change-risk-profile-afghanistan 18 https://ecd.usaid.gov/document.php?doc_id=62152

17https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environ mental-guidelines-resources

16https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environ mental-guidelines-resources https://www.usaid.gov/sites/default/files/2022-12/201mal.pdf https://www.climatelinks.org/resources/climate-change-risk-profile-afghanistan https://ecd.usaid.gov/document.php?doc_id=62152 https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environmental-guidelines-resources https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environmental-guidelines-resources https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environmental-guidelines-resources https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environmental-guidelines-resources

● Training locations and facilities shall be selected that are less vulnerable to the extreme weather events such as flash floods, heat weave etc.

6.0 CONDITIONS AND IMPLEMENTER’S PROCEDURES

1. The implementer shall be responsible for compliance with all conditions herein.

2. Activity should be conducted in a manner compliant with all applicable legislation;

regulation and standards of Afghanistan and national obligations under ratified applicable international environmental agreements and conventions; and in their absence with best management and industry practice acceptable to USAID.

3. The implementer shall minimize the use of, and ensure proper management and disposal of, hazardous materials and waste.

4. For procurement and use of pesticides, if any, the implementer shall adhere to the 2024 USAID/Afghanistan Programmatic-Pesticide Evaluation Report and Safer Use Action Plan (P-PERSUAP). Or if updated.

5. When equipment (computers; etc.) is procured it should be disposed in an environmentally safe manner at the end of its life by a certified company in accordance with local laws, and in the absence of such guidance, in accordance with international best practice acceptable to USAID (alternatively, when procuring equipment from a licensed provider/dealer an agreement may be reached that such equipment will be returned to the dealer for its environmentally safe disposal).

6. As appropriate, the implementer(s) shall obtain necessary approvals from national authorities for environmental compliance documentation, including applicable permits, licenses, etc.

7. All activities shall be consistent with good design and implementation practices acceptable to USAID as described in:

1. USAID’s Sector Environmental Guidelines as provided at https://www.usaid.gov/environmental-procedures/sectoral-environmental-soci al-best-practices/sector-environmental-guidelines-resources

2. EBRD Sub-sectoral Environmental and Social Guidelines at https://www.ebrd.com/downloads/policies/environmental/anfeed.pdf

3. ADB Environmental Guidelines at https://www.adb.org/who-we-are/safeguards/safeguard-policy-statement

4. IFC Environmental; Health and Safety Guidelines as provided at https://www.ifc.org/en/insights-reports/2000/general-environmental-health-an d-safety-guidelines;

5. Any other international best practices readily available from the Organization for Economic Co-operation and Development (OECD), United Nations Environmental/Development Programme (UNEP/UNDP) (or European Union

(EU)).

8. The implementer shall have a qualified, COR and Mission Environmental Officer (MEO)-approved Environmental Professional(s) (EP) who coordinates the implementation of environmental mitigation measures, monitoring, and reporting to the USAID/Afghanistan Agreements/Contracts Officer Representative (A/COR).

Should an EP lack any special technical knowledge to identify any special environmental impact, the implementer will consult with a specialist in the relevant area.

9. Continuous environmental monitoring, evaluation, reporting and supervision will be conducted during project implementation. Quarterly, semi-annual and annual reports, as applicable, will contain sections on environmental compliance. A/COR and the https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environmental-guidelines-resources https://www.usaid.gov/environmental-procedures/sectoral-environmental-social-best-practices/sector-environmental-guidelines-resources https://www.ebrd.com/downloads/policies/environmental/anfeed.pdf https://www.adb.org/who-we-are/safeguards/safeguard-policy-statement https://www.ifc.org/en/insights-reports/2000/general-environmental-health-and-safety-guidelines https://www.ifc.org/en/insights-reports/2000/general-environmental-health-and-safety-guidelines

MEO/CIL will meet with the implementer to explain conditions established in the original and amended IEEs.

10. USAID Social, Economic, and Environmental Accountability Mechanism (SEE-AM) will ensure that people who have been or may potentially be socially, economically, or environmentally adversely affected by USAID programming worldwide have an opportunity to have their concerns and complaints addressed21. The program will also ensure that local communities and other stakeholders have the ability and access to a channel to express their concerns about actual or potential social, economic, and environmental harms resulting from USAID projects or activities and to have these concerns addressed.

7.0 RESOURCE ALLOCATION, TRAINING AND REPORTING

REQUIREMENTS

1. The contract with the implementer shall include a requirement to comply with all conditions of the IEE and any other environmental mitigation and monitoring documentation approved by the Bureau Environmental Officer/Asia. The implementer will be responsible for training its staff and subcontractors on the contract’s environmental requirements and for ensuring compliance of the environmental requirements.

2. The implementer shall have sufficient staff with expertise in an environmental field and resources to implement and report on the expected scope of environmental compliance work. The implementer will document, using cameras/photos, schemes and maps, the status of environmental (and social) conditions on site and in the area of influence prior to, during, and after implementation of projects and activities. This evidence may be also used for providing USAID with lessons learned and best practices.

3. The implementer will have the following documentation and reporting requirements associated with environmental compliance:

a. Mitigation and Monitoring Reports will be submitted to USAID monthly, and not on an annual basis. Reporting will include photographic documentation and site monitoring reports which fully document that all proposed mitigation procedures were followed throughout implementation of the subject work including quantification of mitigation. All such reports and documentation will be submitted to the COR, Management Office and MEO.

8.0 LIMITATIONS OF THE IEE

This IEE does not cover the following:

● Activities involving Genetically Engineered Organisms/GEO (also known as

Genetically Modified Organisms – GMO) may require the preparation of Biosafety Risk Assessment in accordance with ADS 211). The Agency Biosafety Officer (ABO) in the Bureau for Food Security (BFS) must be consulted early in the process to determine if a Biosafety Risk Assessment is necessary. A Biosafety Risk Assessment will require the full collaboration of the Asia BEO, REA/SCA/Afghanistan and Pakistan, Afghanistan MEO/CIL, well as the Agency Biosafety Officer (ABO).

21https://www.usaid.gov/accountability-mechanism/about-see-am https://www.usaid.gov/accountability-mechanism/about-see-am

● Global Development Alliance (GDA) programs.Procurement or use of Asbestos, Lead, Mercury Containing Materials (ALMCM) (i.e. piping, roofing, etc.), Polychlorinated Biphenyl (PCB) containing transformers, or other hazardous/toxic materials for construction projects, including lead and mercury.

● Procurement, use, or recommendation for use of pesticides both in agriculture, and rehabilitation. The contractor shall comply with the approved Pesticide Evaluation Report and Safer Use Action Plan (PERSUAP) or seek MEO/CIL and BEO/Asia guidance on the appropriate course of action.

● Procurement or use of Ammonium Nitrate (AN) and Calcium Ammonium Nitrate (CAN) fertilizers.

Any of these actions would require an amendment to the IEE and the BEO/Asia approval by the BEO/Asia.

9.0 REVISIONS

Pursuant to 22 CFR 216.3(a)(9), if new information becomes available which indicates that activities to be funded by the project might be “major” and the project’s effect “significant,” or if additional activities are proposed that might be considered “major” and their effects significant, this IEE will be reviewed and revised by the originator of the project and submitted to the BEO/Asia for approval and, if appropriate, an environmental assessment will be prepared. It is the responsibility of the USAID A/COR to keep the Mission Environmental Officer, USAID/Afghanistan and the BEO/Asia informed of any new information or changes in scope and nature of the activity that might require revision of the IEE.

Annex [1] CLIMATE RISKS, OPPORTUNITIES, AND ACTIONS for Integrated Health

Initiative program.

* = A required element, according to the Mandatory Reference

1.1: Tasks / Defined or Anticipated Tasks or

Interventions

1.2:

Time-frame

1.3:

Geo-g raphy

2: Climate Risks*

3:

Ad apt ive Ca pac ity

4:

Clima te

Risk Ratin g*

5:

Opport unities

6: How Climate Risks are Addressed in the Activity*

7: Next Steps for Activity Implementati on*

8:

Accepted Climate Risks*

1. Objective 1: Increase Equitable Access to Health and Nutrition Services

2.Objective 2: Improve the Quality of Health Services

3.Objective 3: Healthy Behaviors and Health Seeking Practices Improved

May to April

Kabul, Kandah ar, Herat, Nangar har and Balkh provinc es

Training and their facilities could be affected by flash floods and other extreme climate events.

Increased nutritional needs resulting from increased incidence of diarrhea due to higher temperatures and flood-induced spread of waterborne diseases.

Increased rainfall could affect road conditions and disrupt service delivery, access to health facilities and community health workers, and supply distribution chain, NA mediu m

Increase the capacity of health care and emergen cy services to support disaster planning and manage ment.

Increase medical training to improve awareness and treatment of climate-related health issues.

Improve strategic planning for health services to account for climate change.

Training locations and facilities shall be selected that are less vulnerable to the extreme weather events such as flash floods, heat wave etc.

IP shall review the Agency Climate Strategy (2022-2030) and look for different opportunities and how the activity can contribute to achieve the ambitious goals of the strategy.

Risks have been addressed.