Attachment J.1_ IEE.pdf

AFR/ZAMBIA/ ZAMBIA INTEGRATED HEALTH PORTFOLIO: I.R. 3.2 HEALTH STATUS IMPROVED

IEE TEMPLATE VERSION 3.1

INITIAL ENVIRONMENTAL EXAMINATION

Amendment # 2

PURPOSE

This is Amendment #2 to the Zambia Health Portfolio Initial Environmental Examination (IEE) to include new activities under the Health Portfolio, to revise the funding allocated for this IEE from $1,463,277,115 to $1,641,042,353, explicitly name all activities under the Health Portfolio that were previously not captured, remove activities that have closed out, and to extend the validity period of the IEE. This Amendment also clarifies and formally verifies and transfers Covid-19 related activities previously implemented under the Zambia Covid-19 SIEE as well as verifies and approves the applicability of the COVID-19 Disinfectants PERSUAP for use in USAID/Zambia health programming.

This amendment supersedes previous IEEs.

PROJECT DATA

Project Name: Development Objective 3: Capacity of Zambia’s Government, Citizens, and Private Sector Increased to Improve Health Outcomes and Meet Critical Needs of Vulnerable Populations

Geographic Location(s) (Country/Region): Zambia/Southern Africa Amendment (Yes/No), Yes- Amendment # 2 Implementation Start/End Date (FY or M/D/Y):

FY 2019 – FY 2024

If Amended, specify New End Date: FY 2026 Solicitation/Contract/Award Number(s): Multiple Implementing Partner(s): Multiple Bureau Tracking ID: Zambia Health IEE Amendment 2 Tracking ID of Related RCE/IEE (if any): https://ecd.usaid.gov/repository/pdf/51815.pdf https://ecd.usaid.gov/repository/pdf/39483.pdf Tracking ID of Other, Related Analyses: https://ecd.usaid.gov/repository/pdf/51333.pdf https://ecd.usaid.gov/document.php?doc_id=52754

ORGANIZATIONAL/ADMINISTRATIVE DATA

Implementing Operating Unit(s):

(e.g. Mission or Bureau or Office)

USAID/Zambia

Other Affected Operating Unit(s): USAID/GH/HIDN/MAL and MCH Lead BEO Bureau: AFR Funding Account(s) (if available): USAID/Zambia Original Funding Amount: $1,463,277,115 If Amended, specify funding amount:

If Amended, specify new funding $1,641,042,353 https://ecd.usaid.gov/document.php?doc_id=53719 https://ecd.usaid.gov/repository/pdf/51333.pdf https://ecd.usaid.gov/document.php?doc_id=52754

IEE TEMPLATE VERSION 3.1

total:

Prepared by: Patricia Chisenga, Project Management Specialist Date Prepared: August 23, 2021

ENVIRONMENTAL COMPLIANCE REVIEW DATA

Analysis Type: ☒Environmental Examination

☐Deferral

Environmental Determination(s): ☐Categorical Exclusion(s) ☒Negative determination with conditions ☐Positive ☐Deferred (per 22 CFR 216.3(a)(7)(iv)

IEE Expiration Date (if applicable): FY2026 Additional Analyses/Reporting Required:

Climate Risks Identified (#): Low __5__ Moderate __17__ High _ Climate Risks Addressed (#): Low ___ Moderate __12__ High __ about:blank about:blank

IEE TEMPLATE VERSION 3.1

THRESHOLD DETERMINATION AND SUMMARY OF FINDINGS

PURPOSE AND SCOPE OF IEE AMENDMENT

This is an amendment to the Zambia Health Portfolio Initial Environmental Examination (IEE) amendment #1 that was approved by the Africa Bureau Environmental Officer in October 2020. The purpose of this amendment is to include new activities to the Health Portfolio, to revise the funding allocated for this IEE from $1,463,277,115 to $1,641,042,353, explicitly name all activities under the Health Portfolio that were previously not captured, remove activities that have closed out, and to extend the validity period of the IEE from FY 2024 to FY 2026.

Additionally, this amendment formally transfers Covid-19 actions previously implemented under the USAID/Zambia Covid-19 SIEE (SIEE) into the Zambia health portfolio IEE and its amendments. Covid-19 actions being implemented by the Mission’s partners have similar environmental impacts, threshold determinations, and required mitigation measures as those already being implemented by other health programs (i.e., from an environmental impact perspective, Covid-19 interventions do not differ from those for other transmissible diseases). The Zambia MEO confirmed in January 2022 that the specific actions targeted to Covid-19 are included in the existing Health IEE portfolio, with the exception of the use of disinfectants for combatting infection. Therefore, this IEE amendment also includes the approval of the PERSUAP for Covid-19 Disinfectants (see Annex 4 and 5) and extends the PERSUAP approval to align with the broader health portfolio IEE and its amendments (expiring FY2026). IPs implementing Covid-19 response actions should continue to utilize the AFR Covid PIEE (expiring in March 2022) and the Zambia Covid-19 SIEE as a reference to help draft their Environmental Mitigation and Monitoring Plans (EMMPs), but those documents are no longer the authorizing document for their actions. Rather, this Amendment #2 to the Development Objective 3: Capacity of Zambia’s Government, Citizens, and Private Sector Increased to Improve Health Outcomes and Meet Critical Needs of Vulnerable Populations is now the governing 22 CFR 216 documentation for these actions as the formal replacement for the expiring AFR Covid-19 PIEE and the Zambia Covid-19 SIEE.

This amendment provides the necessary environmental review and documentation, per 22 CFR Part 216, for proposed activities of the USAID/Zambia Health Office. This IEE evaluates proposed activities under the third Development Objective (DO3) of USAID/Zambia’s approved Country Development Cooperation Strategy (CDCS) FY 2019-2024. This five-year IEE sets out to ensure that all current and proposed activities comply with USAID’s environmental regulations.

While Zambia continues to face serious health challenges (as described below), the country has achieved significant advances in the past decade in improving overall health status and in protecting vulnerable groups. 78% of people living with HIV (PLHIV) are on antiretroviral treatment and 69% are virally suppressed. Zambia’s recently released 2018 Demographic and Health Survey shows the rates of infant, child and maternal mortality have all been cut to less than 40% of what they were in 2002. Malaria is also no longer the leading cause of death for children under five years of age. To ensure that Zambia is able to sustain and advance these gains, this DO places an emphasis on enhancing sustainability and self-reliance through locally-led program implementation, decentralized capacity strengthening, improved mobilization and utilization of domestic resources, and increased private sector investment in the health, water, and sanitation sectors.

PROJECT SUMMARY

This IEE is based on the USAID/Zambia Country Development Cooperation Strategy that is valid until July 2024. The long‐term development of Zambia depends on a healthy and productive population. Without significant improvement in health, Zambia cannot achieve its goal of inclusive prosperity by 2030. This https://ecd.usaid.gov/document.php?doc_id=53719 https://ecd.usaid.gov/repository/pdf/39483.pdf https://ecd.usaid.gov/repository/pdf/51815.pdf https://ecd.usaid.gov/document.php?doc_id=52754 https://docs.google.com/document/d/1HF1kgXJ29ZMwRNngtXeXy_BYaTy2wDXt/edit#heading=h.gjdgxs https://docs.google.com/document/d/1HF1kgXJ29ZMwRNngtXeXy_BYaTy2wDXt/edit#heading=h.gjdgxs

IEE TEMPLATE VERSION 3.1

project’s Intermediate Results (IRs) which include, IR 3.1: Utilization of quality health, water, and sanitation services and prevention practices increased; IR 3.2: Health, water, and sanitation systems' effectiveness, capacity and sustainability strengthened, and IR 3.3: Capacity to Protect Vulnerable Populations Enhanced are premised upon the hypothesis that improved capacity to sustain health and welfare outcomes is critical to enhancing Zambia’s Journey to Self-Reliance. If the utilization of high-quality health, water, and sanitation services by Zambians is increased, and if the public and private sector's capacity to plan, finance and implement solutions in these sectors, and to protect vulnerable groups, is strengthened, then Zambia will further advance health and welfare outcomes and sustain those results in the future without external assistance.

To meet its goal, the project must achieve the following sub-intermediate results1:

Sub-IR 3.1.1 - Access to high quality health services increased Sub-IR 3.1.2 - Access to safe water and sanitation improved Sub-IR 3.1.3 - Adoption of healthy (and health-seeking) behaviors increased Sub-IR 3.1.4 - Child malnutrition reduced Sub-IR 3.2.1 - Health care delivery and WASH standards improved Sub-IR 3.2.2 - Human resource capacity increased Sub-IR 3.2.3 - Domestic financing for health and WASH more effectively mobilized and utilized Sub-IR 3.2.4 - Private sector health care provision increased 18 Sub-IR 3.3.1 - GRZ safety net accountability systems improved Sub-IR 3.3.2 - Gender-based violence reduced Sub-IR 3.3.3 - Adolescent pregnancies and marriages reduced Sub-IR 3.3.4 - Early-childhood development programs for vulnerable groups expanded

The overarching development hypothesis is that the USAID suite of mechanisms will result in the following outcomes:

● Increased utilization of health services (public and private sectors)

● Increased use of safe WASH practices

● Increased practice of healthy and health-seeking behaviors

● Reduced stunting rate

● Improved function of health care delivery and WASH systems

● Enhanced provider competencies (clinical and communication skills)

● Improved distribution and delivery of health and WASH funds

● Strengthened private sector platforms, Improved sustainable provision of quality private sector products and services

● Increased accountability of safety net programs

● Reduction of gender-based violence (GBV) occurrences

● Decrease in adolescent birth rates; Decrease in adolescent marriages

● Improved under-five health outcomes; Expanded opportunities for early learning for vulnerable populations

Current and anticipated activities under the USAID/Zambia Health IRs are listed in Table I below.

1 Numbering of intermediate results and outcomes builds upon the CDCS. The project goal is CDCS IR 3.2. Thus, project IR’s become CDCS Sub-IRs and are numbered accordingly.

https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.y04arvyfivjp https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.hxoczvxeltwf https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.c24wj8fect5j https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.tknm5482d9l0 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.eqmnrpxd5o2 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.l736deg6pyp6 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.l736deg6pyp6 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.runpcswjwnis https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.fp144ddrtzab https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.jya5ut3y4u6 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.n70yrzccxwk2 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.e8wzruggv2l1

IEE TEMPLATE VERSION 3.1

ENVIRONMENTAL DETERMINATIONS

While this IEE has received the Negative Determination, this portfolio covers a range of activities that were historically categorically excluded. Categorical Exclusions follow classes of activities, as per 22 CFR 216.2(c)(2), which includes, among others: (i) education, technical assistance, or training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.); (v) document and information transfers; (viii) programs involving nutrition, health care or population and family planning services except to the extent designed to include activities directly affecting the environment (such as construction of facilities, water supply systems, wastewater treatment, etc.); (xiv) 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.); and (xv) activities which involve the application of design criteria or standards developed and approved by USAID.

The health office activities with low environmental risk include:

• Capacity building to communities and MOH for improved community- and facility-based health services through training, technical assistance in clinical diagnosis, treatment, and service delivery, as well as the institutionalization of feedback and reporting systems to ensure accurate reporting of services and commodities as well as quality of care;

• Community engagement to increase demand for quality services and promotion of healthy behaviors;

• Technical assistance for Health Systems Strengthening through, institutionalized quality assurance and quality improvement initiatives for improved healthcare, strengthened human resources for health management at all levels, strengthened data quality, and increased financial sustainability of services including but not limited through introduction of innovative health financing models;

• Monitoring, Learning, Assessment, and Evaluation Activities.

There are qualifiers associated with these activities that were historically categorical exclusions, e.g., if any topic associated with these activities is one that inherently affects the environment, such as training (see below for more information on training that falls under the negative determination with conditions).

Negative Determination with Conditions is recommended for the following illustrative activity classes in the USAID/Zambia health portfolio:

● Some activities (sub elements) of the Family Health and Nutrition (FHN) Technical Assistance.

● HIV/AIDS, malaria, TB, and other diagnostic testing: These activities entail the use, storage, transportation and disposal of blood and/or the generation of medical waste (e.g., used syringes) for diagnostics. These activities present the potential for disease transmission from the generation, management and disposal of blood (including blood products) and medical waste and require appropriate mitigation measures and conditions.

● Treatment of malaria, HIV/AIDS, TB, and other illnesses or health complications during delivery:

Activities such as direct clinical or treatment services have the potential for generation and disposal of medical waste. It is required that best practice approaches be adopted to ensure that adequate application of medical waste management and disposal procedures are exercised.

Management of expired medicines or commodities, and outdated equipment: Activities to support the Government of Zambia with the proper disposal of expired commodities or equipment, particularly those that are procured with USAID resources, are critical.

● HIV/AIDS testing or training related to malaria prevention that involves use and disposal of medical waste, then such training will include information on how to minimize and/or mitigate these impacts. Examples include, instruction on safe disposal of sharps and biological samples generated from HIV/AIDS testing or training in proper household behaviors to minimize

IEE TEMPLATE VERSION 3.1

exposure during indoor residual spraying campaigns and proper use of insecticide-treated materials like bed nets. Likewise, demand creation efforts for VCT, etc., have downstream implications on health care waste management capacity.

● Small-scale water supply and sanitation activities

● Solar energy and construction

● Renovation/refurbishment of physical structures such as maternity annexes, laboratories and health facilities

According to 22 CFR 216.2(d)(2), an Initial Environmental Examination normally will not be necessary for activities within the classes described in 22 CFR 216.2(d), except when the originator of the project believes that the project will not have a significant effect on the environment. In such cases, the activity may be subjected to the procedures set forth in 22 CFR 216.3. According to 22 CFR 216.2(e), the exemptions of 22 CFR 216.2(b)(l) and the categorical exclusions of 22 CFR 216.2(c)(2) are not applicable to assistance for the procurement or use of pesticides.

The Health office has no activities that could potentially rise to positive determination and significantly affect the environment. However, to mitigate any potential environmental impact of these activities, beyond regular monitoring visits to activity sites, the Health Team, in particular, CORs and AORs for individual activities will work with implementing partners to assure, to the extent possible, that relevant medical facilities and operations have adequate procedures and capacities in place to properly handle, label, treat, store transport and properly dispose of blood, sharps, and other medical waste as articulated in the Environmental Guidelines for Small Scale Activities in Africa’s ‘Minimum Elements of a Complete Waste Management Program and USAID Sector Environmental Guidelines – Healthcare Waste2 . Upon approval of this document, the determinations become affirmed, per Agency regulations

(22 CFR 216).

CONSTRUCTION ACTIVITIES

All construction activities will be conducted in an environmentally friendly manner consistent with the SEG Small-Scale Construction (found at:https://www.usaid.gov/sites/default/files/documents/1860/SectorEnvironmentalGuidelines_Constructio n_2017.pdf), USAID Environmental Procedures and host country requirements.

Small-scale construction refers to any individual building that does not exceed 10,000 square feet (1000m2) of construction and less than $200,000 total cost. Projects of this size and cost are unlikely to cause significant adverse environmental impacts. Construction up to several times larger than this “rule of thumb” may still be small-scale, but significant adverse impacts become more likely and require more rigorous consideration and mitigation. USAID constructed facilities, structures, and infrastructure must be designed and constructed to appropriate engineering standards to minimize risk to humans and the natural environment. Burnt bricks contribute to deforestation and any construction should use alternatives such as compressed soil brick and stabilized soil blocks that require very little or no energy to manufacture.

More rigorous monitoring and mitigation measures will be put in place to mitigate the impact on the environment for any activities that may exceed 10,000 square feet (1000m2).

2 https://www.usaid.gov/sites/default/files/documents/1864/FINAL_HCW_SEG_508_12.02.19.pdf https://www.usaid.gov/sites/default/files/documents/1864/FINAL_HCW_SEG_508_12.02.19.pdf

IEE TEMPLATE VERSION 3.1

The table below summarizes the environmental determinations applicable to the three sub-IRs under the Health Office analyzed in this IEE.

TABLE 1: INTERMEDIATE RESULT LIST

Projects/Sub-IRs

Sub-IR 3.1.1 - Access to high-quality health services increased Sub-IR 3.1.2 - Access to safe water and sanitation improved Sub-IR 3.1.3 - Adoption of healthy (and health-seeking) behaviors increased Sub-IR 3.1.4 - Child malnutrition reduced Sub-IR 3.2.1 - Health care delivery and WASH standards improved

Sub-IR 3.2.2 - Human resource capacity increased

Sub-IR 3.2.3 - Domestic financing for health and WASH more effectively mobilized and utilized

Sub-IR 3.2.4 - Private sector health care provision increased Sub-IR 3.3.1 - GRZ safety net accountability systems improved

Sub-IR 3.3.2 - Gender-based violence reduced

Sub-IR 3.3.3 - Adolescent pregnancies and marriages reduced

Sub-IR 3.3.4 - Early-childhood development programs for vulnerable groups expanded https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.y04arvyfivjp https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.hxoczvxeltwf https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.c24wj8fect5j https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.tknm5482d9l0 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.eqmnrpxd5o2 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.l736deg6pyp6 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.runpcswjwnis https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.fp144ddrtzab https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.jya5ut3y4u6 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.n70yrzccxwk2 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.e8wzruggv2l1

IEE TEMPLATE VERSION 3.1

Table 1.1: ILLUSTRATIVE ACTIVITY

Activities

Illustrative Activity 1 - Family Health and Nutrition (FHN)

Illustrative Activity 2 – Malaria Illustrative Activity 3 - HIV/AIDS and TB Illustrative Activity 4 – Small scale Construction and Rehabilitation

Illustrative Activity 5 - Health Systems Strengthening (Governance, financing, information systems, etc.)

Illustrative Activity 6 - Monitoring and Evaluation, Research/Implementation Science

Illustrative Activity 7 - Commodities and Logistics The seven illustrative activities fall in one or more of the sub-IRs in Table 1.

CLIMATE RISK MANAGEMENT

The Climate Risk Management screening results indicated a MODERATE risk to construction and solar as well as commodities and logistics activities. This MODERATE risk will be addressed by RFAs/RFPs developed for individual activities that require implementing partners to address specific climate change risks as part of environmental mitigation and monitoring plan development. Additionally, construction and solar projects are required to practice climate-smart architecture including siting and climate-smart building design and use of materials. A LOW to MODERATE risk is indicated for activities pertaining to HIV/AIDS and tuberculosis and malaria. Increased temperatures, changing precipitation patterns, and increased risk of flooding may increase air and water-borne diseases and vector-borne diseases, which may strain health system resources. These activities are required to integrate climate risk management into their respective Environmental Mitigation and Monitoring Plans (EMMP). LOW risks were identified for the remaining activities of family planning/ reproductive, maternal, newborn, child, and adolescent health and nutrition; health systems strengthening; and monitoring and evaluation. These activities will not require climate risk to be addressed in EMMPs but USAID and Implementing Partners (IPs) will continue to collaborate with the Government of the Republic of Zambia (GRZ) to strengthen climate resilience through planning for extreme weather events, data collection, and behavior change communication.

BEO SPECIFIED CONDITIONS OF APPROVAL

1. Reporting Conditions: As is standard throughout the region, the AFR BEO requests that the activity managers/AORs/CORs provide access to the Regional Environmental Advisor (REA) and to the AFR BEO Team to review (not approve) the Environmental Mitigation and Monitoring Plans/Reports (EMMPs/EMMRs) that will be written to implement the findings of this IEE. These should be uploaded into the appropriate sub-folder(s) of this Google Drive folder:

https://drive.google.com/drive/folders/1q7HGMzgopJ-MuKxkQEJ4GSPp9R7Qzv-5?usp=sharing.

This will facilitate access by all parties who need these documents, including the Mission Environmental Officer and the AOR/COR. This will allow the REA and the BEO Team to spot-check and review these documents to confirm that the mitigations seem appropriate and are cognizant of the specific design of the activities.

https://drive.google.com/drive/folders/1q7HGMzgopJ-MuKxkQEJ4GSPp9R7Qzv-5?usp=sharing

IEE TEMPLATE VERSION 3.1

IMPLEMENTATION

GENERAL IMPLEMENTATION

In accordance with 22 CFR 216 and Agency policy, the conditions and requirements of this document become mandatory upon approval. This includes the relevant limitations, conditions and requirements in this document as stated in Sections 3, 4, and 5 of the IEE and any BEO Specified Conditions of Approval.

SPECIAL ACTIVITY IMPLEMENTATION AND REPORTING NOTES

COVID-19 - IPs implementing Covid-19 response actions should continue to utilize the AFR Covid PIEE (expiring in March 2022) and the Zambia Covid-19 SIEE as a reference to help draft their Environmental Mitigation and Monitoring Plans (EMMPs), but those documents are no longer the authorizing document for their actions. Rather, this Amendment #2 to the Development Objective 3:

Capacity of Zambia’s Government, Citizens, and Private Sector Increased to Improve Health Outcomes and Meet Critical Needs of Vulnerable Populations is now the governing 22 CFR 216 documentation for these actions as the formal replacement for the expiring AFR Covid-19 PIEE and the Zambia Covid-19

SIEE.

The following is applicable only to USAID/Zambia’s implementation of the Program for the Advancement of Malaria Outcomes (PAMO) and Impact Malaria. As such:

The Program for the Advancement of Malaria Outcomes (PAMO), as a field mechanism buy-in, was originally governed by a Programmatic Initial Environmental Examination (PIEE) through Global Health (GH-13-16).3 The PIEE expired in 2018, but the PIEE required supplemental country-level analysis as a condition of the PIEE. The threshold conditions assigned to PAMO actions in this Development Objective 3: Capacity of Zambia’s Government, Citizens, and Private Sector Increased to Improve Health Outcomes and Meet Critical Needs of Vulnerable Population IEE are aligned with the PIEE, but this IEE provides more detail on environmental impacts and conditions which help to inform development of Zambian partners EMMPs as noted below.

Impact Malaria is a field mechanism buy-in to the centrally managed Advancing Progress in Comprehensive Malaria Case Management and Service Delivery Project governed by the IEE of the same name4, which was drafted in 2016 and expires in August 2022. The threshold conditions assigned to Impact Malaria actions in this DO3 Zambia Health IEE are aligned with the Advancing Progress Comprehensive Malaria Case Management and Service Deliver Project IEE but this IEE provides more detail on environmental impacts and conditions which help to inform development of Zambian partners EMMPs as noted below.

For PAMO and Impact Malaria, this DO3 Zambia Health IEE serves to supplement the PIEE or central IEE for implementing partners in Zambia as the DO3 Zambia Health IEE provides additional environmental impacts analysis particular to Zambia and provides mitigation measures that can inform partners on their development of EMMPs. However, while 22 CFR 216 regulatory coverage is brought full circle here, the reporting of EMMPs and annual reporting requirements (EMMRs or EMMTs) and

3 Link to the Maternal Newborn, and Child Project Programmatic IEE:

https://docs.google.com/viewer?a=v&pid=sites&srcid=dXNhaWQuZ292fGFmcmVudnByb2N8Z3g6NTcwZ jllOTU1NmRhNGI1Mg.

4 Link to the Advancing Progress in Comprehensive Malaria Case Management and Service Delivery Project IEE:

https://docs.google.com/viewer?a=v&pid=sites&srcid=dXNhaWQuZ292fGFmcmVudnByb2N8Z3g6NmZh YmM2NTJhMWUzZjhlZA https://ecd.usaid.gov/document.php?doc_id=52754 https://ecd.usaid.gov/document.php?doc_id=52754 https://docs.google.com/document/d/1HF1kgXJ29ZMwRNngtXeXy_BYaTy2wDXt/edit#heading=h.gjdgxs https://docs.google.com/viewer?a=v&pid=sites&srcid=dXNhaWQuZ292fGFmcmVudnByb2N8Z3g6NmZhYmM2NTJhMWUzZjhlZA https://docs.google.com/viewer?a=v&pid=sites&srcid=dXNhaWQuZ292fGFmcmVudnByb2N8Z3g6NmZhYmM2NTJhMWUzZjhlZA

IEE TEMPLATE VERSION 3.1

timelines must flow through the Mission Activity Manager to the cognizant A/COR and their Bureau Environmental Officer, wherever they reside, in accordance with the Programmatic or central IEE. It is the responsibility of the Mission Activity Manager to identify those channels and ensure reporting is commensurate with those requirements as detailed in the parent IEE, as identified.

USAID APPROVAL OF THE INITIAL ENVIRONMENTAL EXAMINATION

PROJECT NAME: Health Portfolio - Capacity of Zambia’s Government, Citizens, and Private Sector Increased to Improve Health Outcomes and Meet Critical Needs of Vulnerable Populations.

Bureau Tracking ID:

Approval:

Sheryl Stumbras, Mission Director Date

Clearance:

Dan Sinclair, Health Office Director Date

Clearance:

Emily Rupp, Program Office Director Date

Clearance:

Michael Capobianco, Office of Acquisition and Assistance

Director Date

Samantha Glover, Resident Legal Officer Date

Clearance:

Robin Sharma, Deputy Mission Director Date

Clearance:

Michael T. Weaver, Regional Environmental Officer Date

Clearance:

Colin Quinn, PhD. Agency Climate Integration Lead Date

Mwewa Katongo, Mission Environmental Officer Date

Concurrence Brian Hirsch, AFR Bureau Environmental Officer

Date

DISTRIBUTION:

AFR BEO and GH BEO Health Office Program Office Office of Acquisition and Assistance Global Heath /HIDN/MCH Office and MAL Offices

IEE TEMPLATE VERSION 3.1

INITIAL ENVIRONMENTAL EXAMINATION

CONTENTS

THRESHOLD DETERMINATION AND SUMMARY OF FINDINGS 3

PROJECT/ACTIVITY SUMMARY 3

ENVIRONMENTAL DETERMINATIONS 4

CLIMATE RISK MANAGEMENT 9

BEO SPECIFIED CONDITIONS OF APPROVAL 9

IMPLEMENTATION 9

USAID APPROVAL OF INITIAL ENVIRONMENTAL EXAMINATION 10

1.0 PROJECT/ACTIVITY DESCRIPTION 13

1.1 PURPOSE OF the IEE 13

1.2 PROJECT/ACTIVITY OVERVIEW 13

1.3 PROJECT/ACTIVITY DESCRIPTION 14

2.0 BASELINE ENVIRONMENTAL INFORMATION 30

2.1 LOCATIONS AFFECTED AND ENVIRONMENTAL CONTEXT (ENVIRONMENT, PHYSICAL,

CLIMATE, SOCIAL, Threatened and ENDANGERED species) 32

● 414.0 ENVIRONMENTAL DETERMINATIONS

4.1 RECOMMENDED ENVIRONMENTAL DETERMINATIONS 46

4.2 CLIMATE RISK MANAGEMENT 50

5.0 CONDITIONS AND MITIGATION MEASURES 51

5.1 CONDITIONS 51

5.2 AGENCY CONDITIONS

5.3 MITIGATION MEASURES 53

6.0 717.0

72ATTACHMENTS:

IEE TEMPLATE VERSION 3.1

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 (22CFR216), is to provide a preliminary review of the reasonably foreseeable effects on the environment of the USAID intervention described herein and recommend a determination and, as appropriate, conditions, for the three Intermediate Results (IRs) IR 3.1: Utilization of Quality Health, Water, and Sanitation Services and Prevention Practices Increased; IR 3.2: Health, Water, and Sanitation Systems' Effectiveness, Capacity and Sustainability Strengthened: and IR 3.3: Capacity to Protect Vulnerable Populations Enhanced. Upon approval, these determinations become affirmed, per 22CFR216 and specified conditions become mandatory obligations of implementation. This IEE also documents the results of the project/activity level Climate Risk Management process in accordance with USAID policy (specifically, ADS 201mal) and formally transfers Covid-19 actions previously implemented under the USAID/Zambia Covid-19 SIEE (SIEE) into the Zambia health portfolio IEE and its amendments.

This IEE is a critical element of USAID’s mandatory environmental review and compliance process meant to achieve environmentally sound activity 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 PROJECT OVERVIEW

The purpose of the Health project is to increase the capacity of the Government of the Republic of Zambia’s (GRZ’s), citizens and private sector to improve health outcomes and meet critical needs of vulnerable populations. This will be accomplished through the following:

● Utilization of quality health, water, and sanitation services and prevention practices increased

● Health, water, and sanitation systems' effectiveness, capacity and sustainability strengthened

● Capacity to protect vulnerable populations enhanced

The project directly responds to the goal under the Country Development Cooperation Strategy (CDCS 2019 - 2024) by “partnering with the Zambian government, civil society and private sector to advance the country’s self-reliance through more effective development choices and governance, enterprise-driven economic growth, and increased resilience among its vulnerable citizens.” The Project intends to intensify its focus on strengthening national and particularly local health systems, as well as by engaging more closely with households and communities to define priority needs and break down cultural and gender barriers and improve health-seeking behavior. Its aim is to continue to build on the progress and lessons learned from USAID Zambia’s past programming in priority areas to further reduce morbidity and mortality through sustainable, systems-level investments, so that all Zambians have the opportunity to actively participate in the economy

Development Objective (DO) 3 as articulated in the CDCS Development Hypothesis: Improved capacity to sustain health and welfare outcomes is critical to enhancing Zambia’s the Journey to Self- Reliance (J2SR). If the utilization of high-quality health, water, and sanitation services by Zambians is increased, and if the public and private sector's capacity to plan, finance and implement solutions in these sectors, and to protect vulnerable groups, is strengthened, then Zambia will further advance health and welfare outcomes and sustain those results in the future without external assistance.

https://ecd.usaid.gov/document.php?doc_id=53719 https://ecd.usaid.gov/repository/pdf/39483.pdf https://ecd.usaid.gov/repository/pdf/51815.pdf

The long‐term development of Zambia depends on a healthy and productive population. Without significant improvement in health, Zambia cannot achieve its goal of inclusive prosperity by 2030. This project is premised upon the hypothesis that improved health service delivery, combined with stronger institutions that are more accountable and an increased practice of healthy community behaviors and healthy lifestyles, will improve the health status of Zambians. To meet its goal, the project must achieve the following intermediate results.

Sub-IR 3.1.1 - Access to high quality health services increased Sub-IR 3.1.2 - Access to safe water and sanitation improved Sub-IR 3.1.3 - Adoption of healthy (and health-seeking) behaviors increased Sub-IR 3.1.4 - Child malnutrition reduced Sub-IR 3.2.1 - Health care delivery and WASH standards improved Sub-IR 3.2.2 - Human resource capacity increased Sub-IR 3.2.3 - Domestic financing for health and WASH more effectively mobilized and utilized Sub-IR 3.2.4 - Private sector health care provision increased 18 Sub-IR 3.3.1 - GRZ safety net accountability systems improved Sub-IR 3.3.2 - Gender-based violence reduced Sub-IR 3.3.3 - Adolescent pregnancies and marriages reduced Sub-IR 3.3.4 - Early-childhood development programs for vulnerable groups expanded

1.3 PROJECT DESCRIPTION

IR 3.1: UTILIZATION OF QUALITY HEALTH, WATER, AND SANITATION SERVICES AND

PREVENTION PRACTICES INCREASED

Increasing the utilization of health and wash services and the adoption of healthy behaviors are critical to improving health outcomes, particularly among vulnerable populations where progress has been slow.

The project will work with Zambians and their institutions and systems to strengthen competencies in areas such as leadership, workforce development, system management, quality of care, supervision, data for decision-making, and health governance and financing. Achievements under this IR will contribute to reaching and maintaining HIV epidemic control, preventing maternal and child deaths, and decreasing the burden of malaria and other diseases, resulting in a healthier and more productive workforce.

SUB-IR 3.1.1 - ACCESS TO HIGH-QUALITY HEALTH SERVICES INCREASED

Access to high-quality health services remains a challenge for many in Zambia. Access, as defined here, is a broad term that includes any challenges that may inhibit or limit individuals from reaching appropriate care or services including, but not limited to distance, cost, availability of services, and social barriers. USAID will work to improve access to both public and private sector health services, a main barrier to increasing utilization of these services, by supporting approaches to equitable health care access for all. The health office will support the MOH’s emphasis on integrating services to increase health access and utilization. Furthermore, the project will employ a patient-centered approach, essential to increasing access and utilization to health services, and will support the provision of quality treatment to people where they are located, including at the community level.

SUB-IR 3.1.2 - ACCESS TO SAFE WATER AND SANITATION IMPROVED

The project will work towards reducing the number of people without access to sustainable wash https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.y04arvyfivjp https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.hxoczvxeltwf https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.c24wj8fect5j https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.tknm5482d9l0 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.eqmnrpxd5o2 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.l736deg6pyp6 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.l736deg6pyp6 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.runpcswjwnis https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.fp144ddrtzab https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.jya5ut3y4u6 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.n70yrzccxwk2 https://docs.google.com/document/d/1cHgWwvlFcupwCMmDrjVzhEI2PuckXngbTxCbnqY3kgo/edit#heading=h.e8wzruggv2l1

IEE TEMPLATE VERSION 3.1

services, thereby contributing to sustainable development, by strengthening the GRZ’s wash services delivery through policy formulation and implementation, institution-building, community and private sector engagement in wash infrastructure, development, and maintenance, financing, governance and water-source protection. USAID will also seek to empower the general population to demand for their right to safe water and sanitation services, increased accountability for wash investments, and generally improved service delivery.

SUB-IR 3.1.3 - ADOPTION OF HEALTHY AND HEALTH-SEEKING BEHAVIORS INCREASED

Social and behavior change (SBC) is a cross-cutting component of USAID Zambia’s health portfolio, and therefore a key element of activities that fall under DO3. SBC will be integrated across the project to ensure that appropriate healthy and health-seeking behaviors (e.g., behaviors conducive to good health, including practicing good hygiene and consuming nutritious food, and increasing demand for modern health services) are selected and effectively targeted within activities to increase the utilization of quality health and wash services as well as the associated uptake of healthy behaviors practiced outside of facilities. This activity will focus on identifying key drivers and barriers to effectively evoke positive behavior change at the necessary structural, social, and individual levels.

SUB-IR 3.1.4 - CHILD MALNUTRITION REDUCED

Through a collaborative partnership with other donors, USAID will provide TA to the GRZ to strengthen coordination, management and monitoring using the scaling up nutrition approach, which is the GRZ’s strategy to reduce widespread stunting among children due to acute malnutrition. Stronger nutrition governance will support sustainable, replicable systems to improve nutrition outcomes.

USAID will continue to promote both nutrition-specific and nutrition-sensitive interventions to reduce stunting and undernutrition among women, adolescents, and children by implementing and scaling up evidence-based interventions. Specifically, USAID will build the capacity of healthcare workers and community health workers through training, mentorship, and provision of job aides, and employ innovative SBC activities to address household-level barriers to recommended maternal, adolescent, infant, and young child health and nutrition practices. USAID will also identify, design, and test cutting-edge solutions to more effectively understand and measure nutrition outcomes and close the knowledge gap on the underlying causes and pathways that lead to acute diarrhea and stunting in Zambia.

IR 3.2: HEALTH, WATER, AND SANITATION SYSTEMS' EFFECTIVENESS, CAPACITY AND

SUSTAINABILITY STRENGTHENED

Strengthening the capacity of Zambia’s health and wash systems to sustainably serve the population is key to enhancing the country’s self-reliance. A strong health system provides services in an accessible, effective, efficient, safe, acceptable, equitable, and sustainable manner. As Zambia moves toward a more decentralized health system, it faces the challenge of providing quality services to widely dispersed and often isolated populations with limited human and financial resources. USAID will increase focus on building the capacity of the public and private sectors to deliver quality, integrated health services and wash services at scale, while empowering the GRZ and key private and local entities to assume increasing responsibility for service delivery and utilization. This also includes building local capacity to prevent, detect and respond to emerging infectious disease threats or public health emergencies.

SUB-IR 3.2.1 - HEALTH CARE DELIVERY AND WASH STANDARDS IMPROVED

USAID will continue to support activities to increase high quality health services. The project will also improve access to safe drinking water through capacity building of health care providers and community volunteers in health care, good hygiene practices, waste management, environmental cleaning, and infection prevention and control to improve health outcomes, avert diarrheal disease and rehabilitate sanitation facilities in select health facilities.

IEE TEMPLATE VERSION 3.1

SUB-IR 3.2.2 - HUMAN RESOURCE CAPACITY INCREASED

The project will continue to enhance health provider competencies (technical, administrative and interpersonal) through strengthening the capacity to review and improve policies and procedures and explore innovative ways to improve management. Improvements will also focus on the recruitment and retention of personnel, enhancing performance management systems, and improving workforce capacity and distribution, including assignment incentives for rural areas. Pre-service and In-service training curricula for midwives and nurses will focus on priority services that reduce maternal and child mortality and malaria. At the facility level, support will focus on training and incentive packages for community health workers, an orientation program for new employees at district and health posts, quality improvement, and supportive supervision. Existing supervisory and quality improvement tools will be reviewed, adapted as needed, and taken to scale in districts of concentration. PEPFAR resources will be leveraged to complete the development and maintenance of a human resources for health inventory (database) that will provide data to inform future human resource investments.

SUB-IR 3.2.3 - DOMESTIC FINANCING FOR HEALTH AND WASH MORE EFFECTIVELY MOBILIZED AND

UTILIZED

Delayed, irregular and incomplete distribution of officially budgeted funds for health and wash services is a major challenge for improving health and wash systems and makes planning and implementation very difficult. The project will expand GRZ capacity to more efficiently allocate scarce financial resources to maximize impact in health and wash sector activities through improvements to local management, planning and budgeting, strengthened healthcare financing, and establishment of a development alliance of local private-sector actors. This project will also work to improve public financial management for health and wash at all levels and promote cost-effective use of limited public resources.

SUB-IR 3.2.4 - PRIVATE SECTOR HEALTH CARE PROVISION INCREASED

USAID Zambia’s goal in engaging the private sector is to change the way of doing business by embracing a market-based approach and shared-value partnerships with the private sector to collaboratively achieve sustainable development outcomes capable of moving Zambia beyond the need for assistance.

USAID will engage the private sector to better meet the health and wash needs of all Zambians. Project activities will apply total market and social-marketing approaches to help the private health care sector to grow, while increasing its contribution to the health of Zambians. The project will continue to engage the formal mining sector - the largest single source of corporate social responsibility activity and resources in Zambia - to increase the impact of investments in malaria control, and work with private pharmacies to expand the number of locations where patients can pick up medicines, decongesting public health facilities and improving access to medicines. USAID will also explore new opportunities to engage with the private sector to improve waste-management practices at health facilities.

IR 3.3: CAPACITY TO PROTECT VULNERABLE POPULATIONS ENHANCED

Improving the capacity of the Zambian government, communities, and citizens to protect the health and welfare of vulnerable populations is critical to achieving the CDCS goal. Activities under this IR will improve resilience and health outcomes among vulnerable households and strengthen Zambia’s social protection platforms, thereby advancing its J2SR. USAID support will focus on increasing sustainability within the social protection sector by improving GRZ planning and budgeting processes, financial management, human resource and workforce planning, and the use of social protection and health data to inform strategic decision-making.

SUB-IR 3.3.1 - GRZ SAFETY-NET ACCOUNTABILITY SYSTEMS IMPROVED

The focus of Zambia’s social safety net program is to improve the resilience and health outcomes of vulnerable households in the four highest-HIV-burden provinces of Zambia (Central, Copperbelt, Lusaka

IEE TEMPLATE VERSION 3.1

and Southern), while strengthening the GRZ social protection platform so that the GRZ can ultimately provide, without external assistance, the majority of a basic package of essential services to vulnerable children and adolescents (VCA). The project will support MCDSS to train community level volunteers in the use of standardized tools and materials, and case-management procedures. It will also support GRZ to assist the volunteers to provide direct VCA services and referrals, and manage the reporting of service delivery, identification of social cash transfer beneficiaries and oversee delivery of funds. The role of community volunteers will be expanded to include delivery of a broader range of VCA services and program reporting. The community volunteers will be supervised by government district level officers, and report to provincial level structures. The GRZ’s social protection systems include the social cash transfer scheme and the public welfare assistance scheme, along with other services provided to low-capacity households and children without adult caregivers. IR 3.3 will strengthen these systems from the household level to the national level, including community support structures linked to the social determinants of health, such as the availability of resources to meet daily needs, access to education and economic opportunities, social support, and social norms that underlie gender inequities in these areas.

SUB-IR 3.3.2 - GENDER-BASED VIOLENCE REDUCED

GBV is a human rights violation, a public health challenge, and a barrier to civic, social, political, and economic participation for women. In Zambia, factors contributing to GBV include initiation ceremonies, economic dependence of women on men, socialization of gender roles for boys and girls at home and in school, inadequate laws on GBV and domestic violence and lack of law enforcement, and intimate-partner violence. The project will work alongside GRZ and other donors to prevent and respond to GBV and sexual violence among girls, boys, women and men, and priority populations such as the physically challenged and key populations. This will be done through improving linkages between community-based HIV and GBV prevention interventions and clinical post-GBV care services. Media campaigns are essential to GBV prevention, combined with group training on gender equality at multiple levels of society, family and community. Addressing gender-based discrimination and inequalities, social norms that tolerate violence against women, and gender roles that promote gender inequality requires changing attitudes, norms and behaviors that result in gender inequality and violence. In addition, empowering women and girls to build personal skills and resources is an important component of GBV prevention

SUB-IR 3.3.3 - ADOLESCENT PREGNANCIES AND MARRIAGES REDUCED

Adolescent girls have high marriage and birth rates in many regions of Zambia.