Attachment J.3.pdf

COVER SHEET

INITIAL ENVIRONMENTAL EXAMINATION (IEE)

PROGRAM/ACTIVITY DATA:

Program/Activity Number: USAID/ Tanzania DO 1 IR 1.2

Program/Activity Title: USAID/Tanzania Health Status Improved

Country/Region: Tanzania

Functional Objective: 3 Investing in People

Program Area: 3.1 Health

Elements: 3.1.1 HIV/AIDS

3.1.2 Tuberculosis

3.1.3 Malaria

3.1.6 Maternal and Child Health

3.1.7 Family Planning and Reproductive Health

2.2.3 Local Government and Decentralization

Period Covered: FY 2016 – FY 2020

LOP Amount: $1,425,000,000

IEE Prepared by: Josh Habib, The Cadmus Group, Inc.;

Jacqueline Kalimunda and Bethany Haberer, Health Office

IEE Amendment (Y/N): No

Current Date: February 2016

Expiration Date: December 2021

Other Relevant Environmental Compliance Documentation:

Tanzania Supplemental Environmental Assessment for Indoor Residual Spraying for Malaria Control 2015-2020

Supplemental Environmental Assessment: Tanzania Vector Control Scale-up Project

Feed the Future Innovation Lab for Rift Valley Fever Control in Agriculture

D02: Inclusive Broad-based Economic Growth Sustained IR 2.1 Binding Constraints to Private Sector Investment Reduced IEE IR 2.2 Agricultural Productivity and Value Chain IEE For WASH activities USAID/Tanzania IR 2.3 Natural Resources Management and Water Portfolio (EG) IEE http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/45566.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/45566.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/41836.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/45051.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/44566.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/45606.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/39933.pdf

ENVIRONMENTAL ACTION RECOMMENDED

Categorical Exclusion X Negative Determination X Positive Determination Deferral

ADDITIONAL ELEMENTS:

EMMP: X Conditions: X PVO/NGO: Pesticides:* X *22 CFR 216.3 (b)(1) applies

SUMMARY OF FINDINGS:

Scope 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 health-related activities expected to be implemented by USAID/Tanzania, as approved in the following Project Authorization Documents (PADs):

• Comprehensive Health Services Delivery (CHSD) PAD (September 2015),

• Community Health Promotion and Services (CHPS)PAD (July 2015),

• Services Delivery Systems Strengthening (SDSS) PAD (April 2015),

• Mobilizing Maternal Health (Vodafone) PAD (September 2013), and

• Gender Equality and Youth Inclusion (in process).

Activities implemented under these PADs will support the USAID/Tanzania Country Development Cooperation Strategy (CDCS) goal of “Tanzania’s socio-economic transformation toward middle income status by 2025 advanced.” This goal will be met through three complementary Development Objectives (DOs) and associated Intermediate Results (IRs).

This IEE will predominantly cover IR 1.2: Health Status improved but also covers health components in activities under the CDCS for:

• DO1: Tanzania women and youth empowered o IR 1.1: Gender Equality and Youth Inclusion o IR 1.3.3: Parental and Community in Education Enhanced

• DO2: Inclusive broad-based economic growth sustained o IR 2.1: Binding constraints to private sector investment reduced o IR 2.2: Agricultural productivity and profitability increased in targeted value chains o IR 2.4: Unmet need for family planning reduced

• DO3: Effective democratic governance improved o IR 3.1: Citizen engagement made more effective o IR 3.2: Government delivery of services improved

• Cross-cutting Intermediate Result (CCIR): Data-driven decision-making, planning and implementation improved

This IEE supersedes the Mission’s previous and recently expired IEEs for SO 10: Reduced Transmission and Impact of HIV/AIDS and SO11: Health Status of Tanzanian Families Improved; except that activities already operating under an approved environmental mitigation and monitoring plan (EMMP) may continue operating under that EMMP.

Projects will be implemented through a number of separate instruments (contract, grant or cooperative agreement). Each instrument consists of a specified set of activities. In order to facilitate environmental review of the entire Health Project, this IEE assesses by tactic type (rather than by individual mechanism), describes potential environmental impacts and makes recommended determinations. For example, if numerous instruments comprising the Health Project entail a similar form of training or capacity building—in, say, disease surveillance—this type of capacity building will be discussed and assessed only once in this IEE and will apply across the sector. This approach limits redundancy (and length) and generally simplifies interpretation of the IEE by USAID staff and partners.

The following table summarizes the tactic categories established for the purpose of environmental review of the health projects. This table also indicates the recommended determination(s) associated with each of the tactic categories.

Table 1: USAID/Tanzania Health Tactic Categories and Preliminary Recommended Determinations

Tactic Category Categorical Exclusion(s)

Negative Determination(s)

Deferral Link to Full Analysis

1) Technical assistance and capacity building to improve delivery of and access to quality health services.

(w/ conditions)

Click here

2) Direct healthcare service delivery focusing on HIV/AIDS, TB services, and family planning outreach

3) Increasing health-seeking behaviors and health social norms through communication and education

4) Direct social and protections services support to vulnerable children and households impacted or affected by HIV/AIDS or gender-based violence

5) Household economic strengthening activities (w/ conditions)

Click here

6) Human resources, advocacy, and organizational Development

7) Support for governance, policy development, and finance instruments

(w/ conditions) Click here

8) Direct procurement of commodities and strengthening of commodities, logistics, and diagnostic systems

9) Small-scale construction http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/861.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/861.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/37609.pdf

Tactic Category Categorical Exclusion(s)

Negative Determination(s)

Deferral Link to Full Analysis

10) Data collection, analysis and information sharing Click here

The tactic categories summarized in Table 1 span a broad set of awards that (a) are currently being implemented by USAID/Tanzania and fall under the aegis of the Health sector or (b) are expected to be implemented as health activities prior to the expiration of this IEE.

General Implementation & Monitoring Conditions Activities undertaken by or through these Project awards are subject to this IEE. In addition to the specific conditions enumerated in Section 3, the negative determinations recommended in this IEE are contingent on full implementation of a set of general monitoring and implementation requirements specified in Section 4 of the IEE.

These require, in summary: 1) IP briefings on Environmental Compliance Responsibilities; 2) development of environmental mitigation and monitoring plans (EMMPs); 3) integration and implementation of EMMPs in work plans and budgets; 4) integration of compliance responsibilities in prime and sub-contracts, and grants/agreements; 5) assurance of sub-grantee and sub-contractor capacity and compliance; 6) Health Team environmental compliance monitoring; 7) 22 CFR 216 documentation coverage for new or modified activities; and 8) compliance with host country requirements.

INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ACTIVITY DATA:

Program/Activity Number: USAID/ Tanzania DO 1 IR 1.2

Program/Activity Title: USAID/Tanzania Health Status Improved

Country/Region: Tanzania

Functional Objective: 3 Investing in People

Program Area: 3.1 Health

Program Elements: 3.1.1 HIV/AIDS

3.1.2 Tuberculosis

3.1.3 Malaria

3.1.6 Maternal and Child Health

3.1.7 Family Planning and Reproductive Health

2.2.3 Local Government and Decentralization

Period covered: FY 2016 – FY 2020

Life of Project Amount: $1,425,000,000

IEE Prepared By: Josh Habib, The Cadmus Group, Inc.;

Bethany Haberer and Jacqueline Kalimunda USAID/Tanzania Health Office

IEE Amendment (Y/N): No

Current Date: February 2016

Expiration Date: December 2021

Other Relevant Environmental Compliance Documentation:

Tanzania Supplemental Environmental Assessment for Indoor Residual Spraying for Malaria Control 2015-2020

Supplemental Environmental Assessment: Tanzania Vector Control Scale-up Project

D02: Inclusive Broad-based Economic Growth Sustained IR 2.1 Binding Constraints to Private Sector Investment Reduced IEE IR 2.2 Agricultural Productivity and Value Chain IEE For WASH activities USAID/Tanzania IR 2.3 Natural Resources Management and Water Portfolio (EG) IEE

This IEE supersedes the Mission’s previous and recently expired IEEs for SO 10: Reduced Transmission and Impact of HIV/AIDS and SO11: Health Status of Tanzanian Families Improved; except that activities already operating under an approved environmental mitigation and monitoring plan (EMMP) may continue operating under that EMMP.

http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/45566.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/45566.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/41836.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/44566.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/45606.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/39933.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/861.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/861.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/37609.pdf

ENVIRONMENTAL ACTION RECOMMENDED

Categorical Exclusion X Negative Determination X Positive Determination Deferral

ADDITIONAL ELEMENTS:

EMMP: X | Conditions: X | PVO/NGO: | Pesticides:* X *22 CFR 216.3 (b)(1) applies

1.0 Background and Activity/Program Description

1.1 Purpose and Scope of IEE

The purpose of this document, in accordance with Title 22, Code of Federal Regulations, Part 216 (22 CFR 216), is to provide a preliminary review of the reasonably foreseeable effects on the environment of health and governance activities under Health Projects, and on this basis, to recommend determinations and, as appropriate, attendant conditions, for these activities. Upon final approval of this IEE, these recommended determinations are affirmed as 22 CFR 216 Threshold Decisions and Categorical Exclusions, and conditions become mandatory elements of project/program implementation.

This IEE addresses activities expected to be implemented by USAID/Tanzania, as encompassed by the mission-wide Health-relevant Project Appraisal Documents (PADs). Activities implemented will support the USAID/Tanzania Country Development Cooperation Strategy (CDCS) objective of “achieving a transformed USAID-Tanzania partnership to strengthen the use of Tanzania’s resources to meet the country’s development needs.” The CDCS objective will be met in the health sector through three complementary Development Objectives (DOs) and associated Intermediate Results (IRs):

• DO1: Tanzania women and youth empowered o IR 1.1: Gender Equality and Youth Inclusion o IR 1.2: Health status improved o IR 1.3.3: Parental and Community in Education Enhanced

• DO2: Inclusive broad-based economic growth sustained o IR 2.1: Binding constraints to private sector investment reduced o IR 2.2: Agricultural productivity and profitability increased in targeted value chains o IR 2.4: Unmet need for family planning reduced

• DO3: Effective democratic governance improved o IR 3.1: Citizen engagement made more effective o IR 3.2: Government delivery of services improved

• Cross-cutting Intermediate Result (CCIR): Data-driven decision-making, planning and implementation improved

Overall funding is estimated at $1,425,000,000, covering FY 16 through FY 20.

For purposes of analysis, this IEE synthesizes current and anticipated Health activities under the office’s various projects and associated initiatives into a set of tactic categories, each of which contains a number of entailed approaches. As with all IEEs, and in accordance with 22 CFR 216, it reviews the reasonably foreseeable effects of each approach on the environment. On this basis, this IEE recommends Threshold Decisions and, in some cases, attendant conditions, for these approaches.

In addition, this IEE sets out project1-level implementation procedures intended to assure that conditions in this IEE are translated into approach-specific mitigation measures, and to assure systematic compliance with this IEE during project and activity implementation. These procedures are themselves a general condition of approval for the IEE, and their implementation is, therefore, mandatory.

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

1.2 Background (Context and Justification)

This IEE addresses all health-related activities expected to be implemented by USAID/Tanzania by the Health Office, as approved in the following Project Authorization Documents (PADs):

• Comprehensive Health Services Delivery (CHSD) PAD (March 2015),

• Community Health Promotion and Services (CHPS)PAD (July 2015),

• Services Delivery Systems Strengthening (SDSS) PAD (April 2015),

• Mobilizing Maternal Health (Vodafone) PAD (September 2013), and

• Tumaini: Gender Equality and Youth Inclusion (in process).

Activities implemented under these PADs will support the USAID/Tanzania Country Development Cooperation Strategy (CDCS) goal of “Tanzania’s socio-economic transformation toward middle income status by 2025 advanced.” This goal will be met through three complementary Development Objectives (DOs) and associated Intermediate Results (IRs).

1.3 Summary of Projects and Activities

Comprehensive Health Service Delivery (CHSD) PAD summary

The objective of the CHSD project is to provide high quality, comprehensive and integrated health services to the people of Tanzania, especially adolescents and women, with a focus on reproductive and child health. In order to achieve high quality, integrated services, various inputs are required and various outputs can be measured. USAID funded activities in these IRs work to ensure that various inputs (e.g., training, commodities, laboratory tests, supervision and mentoring, routine data collection and analysis at the service provision level) are in place and result in a service delivery site that provides the essential services necessary to avert the predominant causes of maternal and child death.

1 The terms ‘project” and “activity” are used throughout this IEE as per USAID’s programming framework and glossary. As such, a project is a set of executed interventions, over an established timeline and budget intended to achieve a discrete development result (i.e. the project purpose) through resolving an associated problem. It is explicitly linked to the CDCS Results Framework. An activity is a sub-component of a project that contributes to a project purpose. It typically refers to an award (such as a contract or cooperative agreement), or a component of a project such as policy dialogue that may be undertaken directly by Mission staff.

This Comprehensive Health Service Delivery PAD covers an eight year period and reflects the process of streamlining management efforts and enhancing the effectiveness of USAID investments to improve health outcomes by integrating health services, as appropriate. The integrated approach under CHSD will improve linkages across the full continuum of care for Tanzanian adolescents, women and children (from pre-pregnancy to antenatal care to intrapartum and postpartum care; and from newborn to child care; from community health promotion, case identification and referral to health facilities.

Some of these services include:

1) Increase access to comprehensive maternal, newborn and child health, family planning and reproductive health services by strengthening referral systems between communities and facilities including validated, completed referrals between community identified cases and health facilities.

2) Support HIV prevention, care and treatment including PMTCT, early infant diagnosis and pediatric HIV. HIV testing and counseling through PITC will form an integral component during FP, under-five, antenatal and postnatal care, early infant diagnosis, community care and TB screening.

3) Support prioritized maternal and child health high impact interventions that focus on improving care during pregnancy (antenatal care), during labor, and during the postpartum period for mother and baby.

4) Support districts and regions to increase accessibility, utilization and quality of health services through increased accountability and responsiveness by supporting results-based financing. As well, support health facilities to provide the complete package of essential health services in line with the GOT’s standards of care.

5) Support clinical and community-based services and interventions to prevent and respond to gender-based violence.

6) Support integration of TB and TB/HIV services through systematically implementing TB control measures including improved infection control both in facilities and homes, and community-based care and treatment that is strongly linked to facilities.

7) Support key malaria intervention areas including distribution and use of ITNs, indoor residual spraying, IPT for pregnant women to improve malaria diagnosis and treatment.

8) Increase access and use of family planning and health services through community outreach, services at static health facilities as well as mobile clinics, and promotion of social marketing of health commodities including contraceptives and community-based distributors.

9) Develop technical, managerial, and logistics capacities of national malaria control programs to undertake vector control programs in a safe and judicious manner. Support national ministries (e.g., MOHSW, PMO-RALG) and health systems (e.g., human resources and health information) to achieve service delivery goals of the healthcare sector.

Community Health Promotion and Services (CHPS) PAD summary

The Community Health Promotion and Services (CHPS) project, which complements the Health Office’s Comprehensive Health Services Delivery and Services Delivery Systems Strengthening projects, play a critical role in meeting national, regional and international goals. Community-based health programs bridge the gap between the formal healthcare system and the communities where vulnerable populations live. Through health promotion and education, community-based health programs equip families and communities with essential information and the self-efficacy needed to practice healthy and health-seeking behaviors. Community actors including local government, civil society organizations, and community health workers break down barriers to accessing healthcare by facilitating referrals to health facilities, and delivering essential health promotion and commodities at the community level.

The CHPS project covers a five-year performance period (FYs 2014–2018) and aims to achieve GHI Strategy Intermediate Result (IR) 3: Improved Adoption of Healthy Behaviors—including Healthcare- Seeking Behaviors, with a Focus on Women and Girls. This is phrased as “IR 1.2.2 Adoption of healthy behaviors including healthcare-seeking behaviors and balanced nutrition” in the Mission’s Country Development Cooperation Strategy. This result will be met primarily through investments in the promotion of healthy behaviors and social norms, use of community-based health services, and access to social welfare services. The CHPS project’s contribution to the Health Office’s goal of Improved Health Status for Tanzanians is linked to the success of Health Office activities across the Tanzania GHI platform. For example, when a community health worker facilitates pre- and postnatal visits for a new mother, it is expected that the woman and her family will receive quality services as a result of USAID’s investments in improving the health facility.

Strengthening of healthcare financing options will ensure that the woman and her family can pay for the health services through the Community Health Fund scheme. With careful consideration, activities from each of the Health Office’s teams will converge at the community and family levels and ensure that vulnerable populations achieve improved health outcomes.

Service Delivery System Strengthening (SDSS) PAD summary

USAID’s Service Delivery Systems Strengthening (SDSS) Project investments work to improve government service delivery in the health, agriculture, education, and other sectors. USAID/Tanzania’s health sector investments in facility-based services and community health promotion and services activities, as well as its agriculture, infrastructure, water and education service delivery are addressed under this Project. The SDSS Project is guided by USAID/Tanzania’s Country Development Cooperation Strategy (CDCS) 2015-2019, as well as strategic thinking from the Global Health Initiative (GHI) strategy and Feed the Future Initiatives. The SDSS Project will be led by the Mission’s Development Objective Three (DO3) Working Team delivering Effective democratic governance improved. The SDSS Project will work to ensure that any results are sustained after USAID support ends, and that institutionalized capacity for ongoing improvement exists. Specifically, the SDSS Project aims to support the GOT to develop a self-reliant local government service delivery system, particularly for health, agriculture, education, and other sectors, that is responsive to the needs of Tanzanians.

The SDSS Project will be implemented within the same timeframe as USAID/Tanzania’s CDCS (FY 2015– 2019). The SDSS Project will advance national level sector systems improvements (in health and education) and multi-sectoral improvements at the district or Authority LGA level. It will also achieve results related to the GHI Strategy Intermediate Result 2: Improved Health Systems to Strengthen the Delivery of Healthcare Services, and the USAID/Tanzania Feed the Future Multi-Year Strategy, Increased investment in agriculture and nutrition related activities, and Improved use of maternal and child health and nutrition service . This result will be met by targeting challenges associated with human resources for health (HRH), health information systems and data use, governance, domestic financing and procurement for health, infrastructure, agriculture, water and sanitation, and education services.

Mobilizing Maternal Health (Vodafone) PAD summary

The purpose of this project initiated in 2013 is to establish community outreach programs for women at risk of delivery complications and to strengthen MNCH service delivery capacity at two rural hospitals as well as the Comprehensive Community-based Rehabilitation in Tanzania (CCBRT) activity at the Maternity Hospital and the Districts hospitals outside of Dar es Salaam that refer to it. The project addresses factors that can directly impact the reduction in maternal and newborn mortality, including the provision of emergency evacuation and referral services for pregnant women at risk and, engaging in preventive and referral measures, which aim to reduce the need for emergency evacuation. The project also contributes by using existing web and cellphone-based tools to support health workers who provide maternal, newborn and child healthcare.

Tumaini: Gender Equality and Youth Inclusion

The purpose of GEYI, in close alignment with CDCS intermediate result (IR) 1.1, is to increase gender equality and youth inclusion. Efforts to achieve this result can be seen in projects and activities across the Mission, and therefore the success of GEYI will largely depend upon the attributable results of other teams. This cross-cutting approach is informed by USAID’s Local Systems Framework, which affirms that sustainability depends on the contributions of multiple and interconnected actors working within multiple local systems.

Activities not managed in-country

Especially for those activities or awards where 1) the mission uses a IQC, IDIQ, RFTOP, LWA mechanism to support mission activities (i.e. Mission AO/CO issues award) or 2) the mission has allocated Mission resources to a central, regional bureau (i.e. Bureau for Africa) or regional mission mechanism (i.e. field support) and where the mission has designated an activity manager, the mission will have oversight responsibilities to assure environmental compliance from the controlling IEEs.

1.4 Tactic Categories for Environmental Review

As noted above, health projects will be implemented through an array of separate instruments; and each instrument consists of a specified set of actions. In order to facilitate environmental review of the entire health portfolio, this IEE assesses potential environmental impacts and makes recommended determinations by tactic category (rather than by individual mechanism). For example, if numerous instruments comprising the Health portfolio entail a similar form of training or capacity building—in, say, disease surveillance—this type of capacity building will be discussed and assessed only once in this IEE and will apply across the projects. This approach limits redundancy (and length) and generally simplifies interpretation of the IEE by USAID staff and partners.

The tactic categories span a broad set of awards that (a) are currently being implemented by USAID/Tanzania and fall under the aegis of the Health sector; or (b) that are expected to be implemented as part of health projects prior to the expiration of this IEE.

For purposes of environmental review and compliance, constituent activities of USAID/Tanzania health portfolio are organized into the following categories:

1. Technical assistance and capacity building to improve delivery of and access to quality health services;

2. Direct healthcare service delivery focusing on HIV/AIDS, TB services and family planning outreach;

3. Increasing health-seeking behaviors and health social norms through communication and education;

4. Direct social and protections services support to vulnerable children and households impacted or affected by HIV/AIDS or gender-based violence;

5. Household economic strengthening activities;

6. Human resources, advocacy, and organizational development;

7. Support for governance, policy development, and finance instruments;

8. Direct procurement of commodities and strengthening of commodities, logistics and diagnostic systems;

9. Small-scale construction; and

10. Data collection, analysis and information sharing.

Each tactic category has a number of associated activities; these will be listed, and, where not self-explanatory, explained in Section 3 of the IEE.

2.0 Country, Environmental and Health Information

2.1 Locations Affected & Baseline Information

Geography, Climate and Topography Tanzania covers a land area of approximately 945,087 km2 comprised of land area of 883,749 km2, (881,289 km2 mainland and 2,460 km2 Zanzibar), plus 59,050 km2 of inland water bodies, and a marine territory of 241,541 km2, or 20% of the national territory, within its 200-mile Exclusive Economic Zone.

Tanzania’s land ecosystems reflect variation in elevation, precipitation, and soils. Annual average rainfall ranges from 200 to 2000 mm, with most of the country receiving less than 1000 mm on average. Rainfall is unimodal in the southern and western parts of the country and bimodal in the northern, eastern, and northern coastal areas. Arid grasslands and savanna ecosystems that receive less than about 400 to 600 mm of rainfall on average extend south from Tanzania’s border with Kenya. Semi-arid areas with 500 to 800 mm of precipitation occupy large central and southeastern zones. Plateau zones (800 to 1500 m in elevation) in western and southern Tanzania support miombo woodlands. Highland areas that are generally above

Map 1: Tanzania; Source: CIA World Factbook

1000 m elevation form a broad ridge that bisects the country along the Eastern Arc Mountains; others follow Tanzania’s western borders between Lakes Nyasa, Tanganyika and Victoria and its boundary with Kenya.2

Socio-economics3 Tanzania has one of Africa’s fastest growing economies. The per capita Gross Domestic Product (GDP) has increased from $1,025 in 2004 to $1,380 in 2012. Yet, widespread poverty persists. In 2012, 28 percent of Tanzanians could not meet their basic consumption needs and 9.7 percent of the population is extremely poor, meaning they cannot afford to buy basic foodstuffs to meet their minimum nutritional requirements. Tanzania’s nearly 7 percent annual national GDP growth since 2000 has been hardly perceptible among Tanzania’s predominantly rural (73 percent) population.

Over the past decade, Tanzania achieved impressive GDP growth rates, averaging nearly 7 percent annually, and attracted substantial foreign direct investment. Recent natural gas discoveries off the coast hold the potential to significantly increase growth rates once reserves come on line in the next seven to ten years. The business climate, however, remains challenging. To achieve its middle income goal by 2025, Tanzania must fast track the implementation of policy and regulatory reforms that promote private investment in key productive sectors; curb corruption; produce a healthy and skilled labor force; and improve infrastructure.

Inclusive broad-based growth is stymied by: (a) low productivity growth in labor-intensive sectors (agriculture employs 77 percent out of total national employment, but the sector grew just 4 percent per year over the past decade) and (b) an unchanging and high population growth rate. Forty-four percent of Tanzania’s current population of 45 million is under 15 years of age. At the current growth rate, Tanzania’s population is projected to reach 70 million by 2025. Gender inequities continue to persist. Salaries paid to women are on average 63 per cent lower than those paid to men, and when women own businesses, they make 2.4 times less profit than men.

In Tanzania, women are disproportionately concentrated in vulnerable forms of work and face occupational segregation and low wages relative to men. This often reflects women’s disadvantages:

their lower rates of education completion; gender norms and stereotypes that track men and women into different fields; and lack of an organized voice and bargaining power. Economic constraints include lack of full-time employment; lack of access to care for children and dependents; lack of transportation;

the pressures of global competition that keep female wages down; and direct discrimination. Growing numbers of youth who are entering Tanzania’s labor force are also at risk. With the rapid population growth in Africa and its implication for the age pyramid, youth unemployment has become a major issue of concern to African governments. In Tanzania, youth unemployment in 2011 was estimated at 13.4%, with female unemployment at 14.3% and male unemployment at 12.3%.

Health Sector As noted in the PADs, despite significant progress over the past 15 years, critical public health challenges in Tanzania remain. For instance, maternal and child deaths, resulting primarily from infectious diseases and lack of access to quality health services, remain high. Maternal health is one of the greatest health challenges in Tanzania, as the maternal mortality rate is 454 per 100,000 live births. Malaria is a major

2 Excerpt from Tanzania Environmental Threats and Opportunities Assessment (ETOA), 2012 3 Excerpt from Tanzania Country Development Cooperation Strategy (CDCS), October 3, 2014-October 3, 2019 and Tanzania Mainland Poverty Assessment http://pdf.usaid.gov/pdf_docs/pnaea222.pdf https://www.usaid.gov/sites/default/files/documents/1860/CDCS%20Tanzania%20FINAL.pdf http://www.worldbank.org/content/dam/Worldbank/document/Africa/Tanzania/Report/tanzania-poverty-assessment-05.2015.pdf cause of maternal mortality, and also the leading cause of death amongst children in Tanzania (prevalence is lower in Zanzibar). In mainland Tanzania, more than 40 percent of outpatient visits are due to malaria, resulting in 10-12 million malaria cases annually, of which 60,000 to 80,000 result in death. Some improvement has been seen in the prevalence of infectious diseases, attributable to improved health behaviors such as immunizations for children and the use of insecticide-treated bed nets. In 2005, Tanzania was selected as one of the first focus countries for the President’s Malaria Initiative (PMI), through which major progress has been made in malaria control; improvements have been seen in nearly all malaria indicators between 2005 and 2010.4

In FY 2015, PMI worked with national and local GOT entities to provide household spraying, bed nets, malaria case management, and other high impact interventions. According to the 2011/2012 Tanzania HIV and Malaria Indicator Survey, more than 70 percent of young children and pregnant women -groups most at risk of malaria infection - slept under an ITN the night before the survey. This represents a four-fold increase since 2004-05. Despite substantial improvement in prevention practices, malaria still poses a significant threat to children. Nine percent of children between 6 to 59 months of age tested positive for malaria nationwide, and in four regions more than 20 per cent of young children tested positive.

Tanzania also faces a generalized HIV epidemic on the Mainland, and a concentrated HIV epidemic in the Zanzibar archipelago. An estimated 1.4 million Tanzanians are infected with HIV and each year 100,000 new infections occur and 80,000 people die from the infection. There are also significant gender differences in HIV prevalence; prevalence is higher for women than men in almost every age group except 35-39. Overall, male prevalence was 3.8 percent in 2011/12 while female prevalence was 6.2 percent.5 TB remains the leading cause of death amongst people living with HIV, and Tanzania is in the top 22 countries with the highest TB burden.6

AIDS-related mortality has resulted in widespread disruption of family structures; nearly 10% of children in Tanzania have lost one or both parents, many of these deaths caused by AIDS. Social and gender norms, such as early marriage and gender-based violence, also pose significant barriers to health and development, particularly for girls. Tanzania has made some positive steps in the effort to reduce HIV/AIDS; because of community outreach efforts, most adults now know where to get an HIV test and 62 percent of women and 47 percent of men have received HIV tests.7

Only 43 percent of women make all four recommended pre-natal care visits, and only about half of births are attended by a skilled health professional. Women face social and gender norms, which further hinder their health and development. Tanzania is one of the lowest-ranked countries in the world for gender equality, and gender-based violence is common, with 44 percent of women reporting having experienced physical violence, and 20 percent having experienced sexual violence.8

USAID voluntary family planning programs are being integrated with other health services to contribute to the goal of reducing maternal mortality. Although the total fertility rate in Tanzania has fallen from

4 PMI, Tanzania; 2015; accessed via the internet on 10/19/2015 5 Tanzania 2011-2012 HIV/AIDS and Malaria Indicator Survey, March 2013 6 USAID/Tanzania Country Development Cooperation Strategy (CDCS) October 3, 2014- October 3, 2019 7 USAID/Tanzania Community Health Promotion and Services PAD 8 USAID/Tanzania Community Health Promotion and http://www.pmi.gov/docs/default-source/default-document-library/country-profiles/tanzania_profile.pdf?sfvrsn=14 https://dhsprogram.com/pubs/pdf/AIS11/AIS11.pdf https://www.usaid.gov/sites/default/files/documents/1860/CDCS%20Tanzania%20FINAL.pdf

5.7 to 5.4 births per woman in recent years, there have been no significant changes in the country's unmet need for family planning. The use of modern contraception in Tanzania has increased from 20 percent to 27 percent between 2005 and 2010, with use of any family planning method increasing from 26 percent to 34 percent. After sustained efforts to improve contraceptive security and logistics, national contraceptive distribution has improved, but resource allocation and stock-outs remain problematic. Social marketing and communication are having an impact with rising sales of oral contraceptives and condoms.

Shortfalls in health systems and care delivery exacerbate these health crises. Decentralization, beginning in 1996, moved service delivery and organization responsibilities from the central level to the district level, but localized service delivery is hampered by lack of budget authority, weak management capacities, and incomplete decentralization of some core functions. In addition to improving health systems strengthening, USAID aims to reduce inequality and increase access to healthcare and health-related information.9

Water Resources10,11,12

Water resources are crucial to Tanzania’s economy. Water is key to agricultural productivity, industrial production and workforce support in urban areas, electricity provision and service provision, as well as tourism. However, Tanzania is experiencing growing water scarcity due to population growth and a high level of variability in water resources, both spatially and temporally. While the Lake Tanganyika basin and southern highlands can receive up to 3,000 mm of rainfall annually, half the country receives less than 765 mm annually. Further, northern Tanzania experiences long rains from March to May and short rains from October to December, while the rest of the country experiences the majority of rainfall between December and April.

Major cities in Tanzania source water from the country’s rivers; Dar es Salaam, Morogoro, Kibaha and Dodoma are supplied by the Wami-Ruvu river basin, while the Kilimanjaro District (including Arusha) is supplied by the Morogoro, Kibaha and Dodoma. Most urban areas use groundwater as a supplement to surface water, except Zanzibar, which relies primarily on groundwater. In Dar es Salaam, shortfalls in piped water supply are compensated for by unregulated private or community boreholes into the cities’ groundwater reserves, many of which are affected by salt water intrusion, or industry pollution and waste disposal. Further, the Wami-Ruvu river basin water quality and quantity is deteriorating due to deforestation, poor land and water use practices, illegal alluvial gold mining and direct pollution.

For those rural Tanzanians that do not live near one of the three major lakes bordering the country, groundwater is the main water source. However, almost half of the population does not have access to safe water. Many wells are proximate to sources of contamination, which leak into the fresh groundwater. As a result, Tanzanians turn to surface water, which also contains bacteria or human waste. Due to unsanitary water resources, over half of the diseases affecting the population are water-borne illnesses, such as diarrheal diseases. In addition to diseases from contaminated water, women and children can spend up to seven hours a day in rural areas collecting water, leaving them susceptible

9 Ibid 10 Water in Crisis- Tanzania, The Water Project, Accessed via the Internet on 15 February 2015 at :

http://thewaterproject.org/water-in-crisis-tanzania 11 The Economics of Climate Change in Tanzania, Water Resources, Accessed via the internet on 15 February 2015 12 Tanzania, Water Futures, Accessed via the internet on 15 February 2015 http://thewaterproject.org/water-in-crisis-tanzania http://economics-of-cc-in-tanzania.org/images/Water_resources_final_.pdf http://www.water-futures.org/countries/tanzania.html to attacks. The Tanzanian Gender Networking Program (TGNP) found that a lack of safe, sufficient and affordable water affects the number of girls leaving school. The TGNP also found that it also increases gender-based violence.

NOTE: WASH activities are covered in the USAID/Tanzania IR 2.3 Natural Resources Management and Water Portfolio (EG) IEE

2.2 Applicable Host Country Health, Environmental and Social Laws, Regulations and Policies 13

Several initiatives have also been taken by government institutions and donors to make operational the use of EIA in development planning.

Environmental Management Act No. 20 of 2004. Tanzania’s 1997 National Environment Policy provides a framework still being utilized for environmental considerations and decision-making to ensure sustainability, security, and equitable use of resources. This is critical to meeting basic needs of present and future generations, without degrading the environment or risking health or safety; to prevent and control degradation of land, water, vegetation, and air, which constitute life support systems; to conserve and enhance the natural and man-made heritage, including the biological diversity of the unique ecosystems of Tanzania. The policy was followed by the enactment of Environmental Management Act, 2004, which provides the legal and institutional framework for sustainable management of the environment, prevention and control of pollution, waste management, environmental quality standards, public participation, environmental compliance and enforcement.

Local Government District Authorities Act No 7 of 1982 & Local Government Urban Authorities Act No 8 of 1982. According to the Local Government (District Authorities) Act of 1982 and Local Government (Urban Authorities) Act of 1982 and their amendments, the village, district and urban authorities are responsible for planning, financing and implementing development programs within their areas of jurisdiction. They are obligated to protect and properly utilize the environment for sustainable development. The Act also empowers the local authorities to make by-laws, which are applicable in their areas of jurisdiction. In practice, however, local governments are unable to make important decisions independently because many legal provisions make the local government dependent on the central government.

In Tanzania, recognition of environmental impact assessment in supporting effective health policy and sustainable development is demonstrated in a series of official policies and strategies. They call for the use of Environmental Impact Assessment (EIA) as a key policy implementation and development tool.

Relevant policies and strategies include:

· National Health Policy

· Health Sector Strategic Plan IV (HSSP IV)

· Health Sector HIV Strategic Plan III (HSHSP III)

· National Multisectoral HIV and AIDS Framework (NMSF)

· Tanzania Quality Improvement Framework

· National Family Planning Costed Implementation Programme

13 Except for the subsection on “Environmental Management Act No.20 of 2004”, this section is an excerpt from the Tanzania Environmental Threats and Opportunities Assessment (ETOA), 2012 http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/39933.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/39933.pdf http://pdf.usaid.gov/pdf_docs/pnaea222.pdf

· The National Road Map to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008-2015

· Malaria Strategic Plan

· National TB and Leprosy Strategic Plan IV

· National Nutrition Strategy

· National Costed Plan of Action for Most Vulnerable Children II

· Health Financing Strategy

In addition, various GOT regulations address proper health care waste management, as shown in the table below:

Tanzania Legislation on Health Care Waste Management

REGULATION PROVISION or GUIDANCE

Public Health Act, 2009 Section 89 of the Public Health Act requires healthcare waste to be managed in accordance with the guidelines and standards under the Environmental Management Act.

Environmental Management Act

(EMA), 2004

Department of Environment at the National Environment Management Council (NEMC) collaborates with the Ministry of Health and Social Welfare (MoHSW) to:

• Ensure that healthcare wastes are sorted and stored in prescribed coded containers and transported and disposed of via registered healthcare wastes refuse trucks designed; and

• Prescribe the best possible method for final disposal of various types of healthcare wastes.

Occupational Health and Safety Act of 2003

Safety and Health Inspectors are required to inspect all workplaces to determine whether they are in compliance with OHS legislation and standards, specifically:

• Regular inspection, supervision and monitoring to assess the safety practices at health institutions.

• Staff should be trained in the application of safety standards so that they are aware of the potential risks in non-compliance.

• Accidents should be reported and dealt with in accordance with established protocols.

• Persons who handle healthcare waste should be provided with protective gear and clothing as recommended by WHO guidelines.

Healthcare Waste Management National Policy Guidelines

Identify appropriate HCWM methods that can be applied in healthcare facilities and within communities, including:

• Providing a better knowledge of the fundamentals of HCWM planning and better understanding of the hazards linked to HCWM.

• Developing HCWM plans, standards and procedures that are in compliance with the current environment and public health legislations of Tanzania

• Setting priority actions to tackle most sensitive problems related to HCWM

• Reviewing appropriate and sustainable technology to treat and dispose of HCW

• Analyzing HCWM challenges at health care facilities and developing strategies for safe management of HCWM;

• Developing public private partnerships for investments in HCWM.

Healthcare Waste Management Monitoring Plan

Provides monitoring guidelines for stakeholders involved in healthcare waste management at central, regional, district and local levels. Contains template and checklists for the monitoring plan to be used by all levels. This document helps to:

• Establish actions that must be performed as a minimum to ensure the safe handling and disposal of HCW.

• Establish/develop indicators that demonstrate that mitigation actions/activities are implemented.

• Develop tools for information collection, analysis and construction of the indicators; and

• Define institutional arrangement and assignment of duties, roles/responsibilities for those monitoring HCWM activities National Standards and Procedures for Healthcare Waste Management in Tanzania

Provides technical information for planning and implementation of HCWM, including technical operations of HCWM and recommended best practices. Also includes a summary of standards and specifications regarding selected HCW treatment options.

Potential Environmental Impacts and Recommended Determinations, including Conditions

As set out in section 1.4, for the purpose of environmental review, current and anticipated activities in the USAID/Tanzania Health portfolio are grouped into the following tactic categories. This IEE includes several illustrative activities for each tactic category.

Specific tactic categories are:

1. Technical assistance and capacity building to improve delivery of and access to quality health services;

2. Direct healthcare service delivery focusing on HIV/AIDS, TB services and family planning outreach;

3. Increasing health-seeking behaviors and health social norms through communication and education;

4. Direct social and protections services support to vulnerable children and households impacted or affected by HIV/AIDS and/or gender-based violence;

5. Household economic strengthening activities;

6. Human resources, advocacy, and organizational development;

7. Support for governance, policy development, and finance instruments;

8. Strengthening of commodities, logistics and diagnostic systems, and direct procurement of commodities;

9. Small-scale construction; and

10. Data collection, analysis and information sharing.

Each category contains a number of activities. In Sections 3.1 – 3.10, the activities are described and their potential impacts analyzed. On this basis, Recommended Determinations are made. In most cases, Negative Determinations with conditions. Upon approval of this IEE, implementation of these conditions becomes mandatory.

Section 3.11 addresses the general impacts of waste generated in conjunction with health care systems.

Although waste may not be directly generated by USAID support, by supporting health systems in general, it is a reasonable and an ethical responsibility to consider how to address health care waste and to improve waste treatment and disposal.

3.1 Tactic Category 1: Technical assistance and capacity building to improve delivery of and access to quality health services.

This tactic category consists of the following activities:

1) Pre- and in-service training and supportive supervision of health care providers on clinical interventions and norms for service delivery to improve quality of and access to care. Health care provider refers both to clinical workers in the formal health system (i.e., in health facilities) as well as NGO staff, birth attendants, community health workers and others who provide care at the community level. Pre-/in-service training and supportive supervision areas may include, but are not limited to:

▪ Health care workers and/or service delivery agents, where trainee does not handle medical waste e.g., case managers, promotional messengers) as a function of their position on topics related to family planning, reproductive health, maternal, newborn and child health, nutrition, HIV, TB, malaria, gender-based violence (GBV), or antenatal/post-natal care and…