Attachment J.6.pdf

USAID/DRC

HEALTH PORTFOLIO 2022 – 2027

INITIAL ENVIRONMENTAL

EXAMINATION

PROJECT/ACTIVITY DATA

Project/Activity Name: DRC Health Office Portfolio Geographic Location(s) (Country/Region): Democratic Republic of the Congo/East Africa Amendment (Yes/No), if Yes indicate # (1, 2...): No Implementation Start/End Date (FY or M/D/Y): FY 2022 – October 1, 2027 If Amended, specify New End Date: NA Solicitation/Contract/Award Number(s): Multiple Implementing Partner(s):

Bureau Tracking ID: DRC Health Office Portfolio IEE https://ecd.usaid.gov/document.php?doc_id=45611 Tracking ID of Related RCE/IEE (if any):

Tracking ID of Other, Related Analyses:

ORGANIZATIONAL/ADMINISTRATIVE DATA

Implementing Operating Unit(s):

(e.g., Mission or Bureau or Office)

USAID/DRC

Other Affected Operating Unit(s):

Lead BEO Bureau: AFR Funding Account(s) (if available):

Prepared by: USAID/DRC/Health Office with support from ECOS Date Prepared: February 2022

ENVIRONMENTAL COMPLIANCE REVIEW DATA

Analysis Type: ☒Environmental Examination ☐Deferral Environmental Determination(s): ☒Categorical Exclusion(s)

☒Negative ☒Positive ☐Deferred (per 22 CFR 216.3(a)(7)(iv)

IEE Expiration Date (if applicable):

Additional Analyses/Reporting Required: EMMP, IWMP, EMMR Climate Risks Identified (#): Low ___9___ Moderate ___13___ High ___2___ Climate Risks Addressed (#): Low ___9___ Moderate ___13___ High ___2___ https://ecd.usaid.gov/document.php?doc_id=45611 about:blank about:blank about:blank

HEALTH PORTFOLIO 2022 – 2027

THRESHOLD DETERMINATION AND SUMMARY OF FINDINGS

PROJECT SUMMARY

This IEE addresses activities anticipated under the USAID/DRC's Health Office portfolio by providing a preliminary review of the reasonably foreseeable effects of health-related activities on the environment. The DRC Health Office portfolio is positioned to improve health outcomes in the DRC by continuing the implementation of evidence-based interventions to increase access to high impact HIV/AIDS, tuberculosis, malaria, maternal and child health, family planning, reproductive health, and routine immunization services. Activities implemented will support USAID/DRC’s 2020-2025 Country Development Cooperation Strategy (CDCS) goal of “A More Peaceful and Prosperous DRC with Improved Opportunities for Communities and Individuals to Thrive”.

ENVIRONMENTAL DETERMINATIONS

Upon approval of this document, the determinations become affirmed, per Agency regulations

(22 CFR 216).

INTERVENTION CATEGORIES

Health Office portfolio activities comprise family planning, reproductive health, maternal & child health, routine immunization, and HIV/AIDS, tuberculosis, and malaria response. This analysis addresses the following Intervention Categories that can be expected under this IEE:

Intervention Category 1 Healthcare Provider Training: Healthcare Workforce Strengthening & Development

Intervention Category 2 Direct Procurement of Commodities & Strengthening of Commodities, Logistics & Diagnostic Systems

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

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

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

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

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

HEALTH PORTFOLIO 2022 – 2027

TABLE 1: ENVIRONMENTAL DETERMINATIONS

Intervention Categories Categorical Exclusion Citation (if applicable)a

Negative Determination

Positive Determination1

Deferral2

Category 1: Healthcare Provider Training: Healthcare Workforce Strengthening & Development Sub-intervention 1.1:

Provide capacity building to frontline health workers

1.2: Provide technical assistance and training for health promotion activities

Category 2: Direct Procurement of Commodities & Strengthening of Commodities, Logistics & Diagnostic Systems Sub-intervention 2.1:

Capacity building to support critical policy and strategy reforms to supply chain management

2.2: Improve commodity procurement and supply chain management strategies to ensure availability of health products

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

Category 3: Direct and Capacity Building Support for Health Service Delivery, Excluding Commodity Procurement/ Supply Chain Strengthening Sub-intervention 3.1:

Expand access to and use of malaria, maternal and child health, nutrition, and family planning and reproductive health services

3.2: Support the provision of health services delivery

3.3: Improve TB detection, treatment, and prevention programs

3.4: Improve provision of and demand for quality HIV/AIDS health care services

Category 4: Social Marketing, Education, & Behavior Change Communication Sub-intervention 4.1:

Support strategic leadership, coordination, and participatory social and

§216.2(c)(2)(v), (viii) ☐ ☐ ☐

1 Positive Determinations require preparation of a Scoping Statement and Environmental Assessment.

2 Deferrals must be cleared through an Amendment to this IEE prior to implementation of any deferred activities.

HEALTH PORTFOLIO 2022 – 2027

Intervention Categories Categorical Exclusion Citation (if applicable)a

Negative Determination

Positive Determination1

Deferral2 behavior change (SBC) interventions 4.2: Support community and private sector participation in SBC interventions

§216.2(c)(2)(v), (viii) ☐ ☐ ☐

Category 5: Policy and Strategy Development and Assistance Sub-intervention 5.1:

Identify critical policy and strategy reforms to support, excluding supply chain management

5.2: Engage with, and provide technical assistance to the Government of DRC and other relevant stakeholders

Category 6: Studies, Surveys/ Public Health Surveillance and other Data-Gathering Assessments and Analysis, Models, and Capacity Building in Support of All Areas Above Sub-intervention 6.1:

Conduct public health surveillance activities and studies that include collection of biological samples

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

§216.2(c)(2)(iii), (v), (viii), (xiv)

6.3: Conduct demographic and health surveys

§216.2(c)(2)(iii), (viii), (xiv) ☐ ☐ ☐

Category 7: Technical Assistance to Malaria Vector Control Sub-intervention 7.1:

Insecticidal-Treated Nets (ITN) Distribution

Category 8: Small Scale Construction or Rehabilitation of Health Infrastructure (<10,000 sq. ft) Sub-intervention 8.1:

Construction of small-scale facilities and/or limited refurbishment at existing facilities

Category 9: Resource/ Financial Mobilization Sub-intervention 9.1:

Transfer of (cash) resources to promote health strengthening efforts

§216.2(c)(2)(v), (viii) ☐ ☐ ☐

9.2: Improve budgeting and financial management systems

§216.2(c)(2)(v), (viii), (xiv) ☐ ☐ ☐

HEALTH PORTFOLIO 2022 – 2027

a Categorical Exclusions included in this IEE include the following §216.2(c)(2):

(iii) Analyses, studies, academic or research workshops and meetings;

(v) Document and information transfers;

(vii) 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.)

CLIMATE RISK MANAGEMENT

Section 4.2 summarizes the methodology used and findings of the Climate Risk Management (CRM) Screening, in accordance with ADS 201mal. The CRM analysis established that climate risks were mostly low to moderate for planned interventions. See Annex 1 for the complete CRM table.

BEO SPECIFIED CONDITIONS OF APPROVAL

The negative determinations recommended in this IEE are contingent on full implementation of specified conditions and a set of general monitoring and implementation measures specified in Section 5 of the IEE.

The positive determinations recommended in this IEE must comply with the established conditions in full and adhere to all existing governing Environmental Assessment documentation

– where applicable – or initiate preparation of a new Environmental Assessment, beginning with the preparation of a Scoping Statement.

Reporting Conditions: 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

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.

Training, supervision, curricula development and other health care workforce capacity building must address appropriate management practices concerning the proper handling, use, and disposal of medical waste, including blood, sputum, and sharps, when techniques or care situations being addressed would generate and require disposal of hazardous or highly hazardous waste (e.g., sharps, afterbirth from delivery, waste from screening for HIV or STIs, sputum samples for diagnosis of TB). Note that this condition applies to activities targeting home care and community health workers, not just those in clinics and health facilities.

Wherever relevant, appropriate disposal mechanisms in home-based and community-based situations that are cost effective and safe must be identified and appropriately incorporated in training, protocols, and guidelines. This includes training home care and community health https://www.usaid.gov/ads/policy/200/201mal https://drive.google.com/drive/folders/1q7HGMzgopJ-MuKxkQEJ4GSPp9R7Qzv-5 https://drive.google.com/drive/folders/1q7HGMzgopJ-MuKxkQEJ4GSPp9R7Qzv-5

HEALTH PORTFOLIO 2022 – 2027

workers to deliver positive messages about personal and household hygiene, sanitation, and proper disposal of condoms and other potentially harmful materials.

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.

HEALTH PORTFOLIO 2022 – 2027

USAID APPROVAL OF INITIAL ENVIRONMENTAL EXAMINATION

PROJECT/ACTIVITY NAME: _DRC Health Office Portfolio

Bureau Tracking ID: https://ecd.usaid.gov/document.php?doc_id=45611

Approval: Cleared 06/17/2022 Paul Sabatine, Mission Director Date

Clearance: Cleared 05/31/2022 Ana Bodipo-Mbuyamba, Health Office Director Date

Clearance: Cleared 06/17/2022 Diane-Elizabeth Mbanzidi, Mission Environmental Officer and Mission Climate Integration Lead

Date

Clearance: Cleared 06/15/2022 David Kinyua, Regional Environmental Advisor Date

Clearance: Cleared 06/21/2022 Colin Quinn, Climate Integration Lead Date

Concurrence: 07/14/2022 Brian Hirsch, Bureau Environmental Officer Date

DISTRIBUTION:

https://ecd.usaid.gov/document.php?doc_id=45611

HEALTH PORTFOLIO 2022 – 2027

INITIAL ENVIRONMENTAL

EXAMINATION

CONTENTS

1.0 PROJECT/ACTIVITY DESCRIPTION 9

1.1 PURPOSE OF the IEE 9

1.2 ACTIVITY OVERVIEW 9

1.3 ACTIVITY DESCRIPTION 10

2.0 BASELINE ENVIRONMENTAL INFORMATION 16

2.1 LOCATIONS AFFECTED AND ENVIRONMENTAL CONTEXT (ENVIRONMENT,

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

2.2 APPLICABLE AND APPROPRIATE PARTNER COUNTRY AND OTHER

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

POLICIES, AND REGULATIONS 19

2.3 COUNTRY/MINISTRY/MUNICIPALITY ENVIRONMENTAL CAPACITY ANALYSIS

(AS APPROPRIATE) 22

3.0 ANALYSIS OF POTENTIAL ENVIRONMENTAL RISK 24

3.1 ADVERSE IMPACTS OF HEALTH CARE SERVICE DELIVERY DUE TO FAILURE

TO PROPERLY MANAGE RESULTING WASTES 24

3.2 POTENTIAL ENVIRONMENTAL AND SOCIAL IMPACTS PER INTERVENTION

CATEGORY 26

4.0 ENVIRONMENTAL DETERMINATIONS 32

4.1 RECOMMENDED ENVIRONMENTAL DETERMINATIONS 32

4.2 CLIMATE RISK MANAGEMENT 34

5.0 CONDITIONS AND MITIGATION MEASURES 36

5.1 CONDITIONS 37

5.2 AGENCY CONDITIONS 38

5.3 MITIGATION MEASURES 39

6.0 LIMITATIONS OF THIS INITIAL ENVIRONMENTAL EXAMINATION 45

7.0 REVISIONS 45

ATTACHMENTS: 45

Annex 1. Project Climate Risk Management Summary Table 47 Annex 2. List of All USAID/DRC Health Office Activities (Mission and Centrally-Managed) Cross-Walked With Governing Environmental Compliance Document(s) 54

HEALTH PORTFOLIO 2022 – 2027

1.0 PROJECT/ACTIVITY DESCRIPTION

1.1 PURPOSE OF THE IEE

The purpose of this document, in accordance with Title 22, Code of Federal Regulations, Part 216 (22 CFR 216), is to provide a preliminary review of the reasonably foreseeable effects on the environment of the USAID intervention described herein and recommend determinations and, as appropriate, conditions, for these activities. Upon approval, these determinations become affirmed, and specified conditions become mandatory obligations of implementation.

This IEE also documents the results of the Climate Risk Management process in accordance with USAID policy (specifically, ADS 201mal).

This IEE is a critical element of USAID’s mandatory environmental review and compliance process meant to achieve environmentally sound design and implementation. Potential environmental impacts should be addressed through formal environmental mitigation and monitoring plans (EMMPs) and/or Environmental Assessments (EAs), if needed.

1.2 ACTIVITY OVERVIEW

USAID/DRC’s Health Office portfolio is positioned to improve the health outcomes of the Congolese by continuing the implementation of evidence-based interventions to increase access to high impact HIV/AIDS, tuberculosis, malaria, maternal and child health, family planning, reproductive health, and routine immunization services. Additionally, activities will provide sustainable improvements to governance, supply chain, human resources, financing, and service delivery. All activities undertaken by USAID/DRC Health Office are described in Annex 2, including centrally-managed activities that are covered under other governing environmental compliance documents and thus are not addressed in this IEE. For the environmental compliance documents for activities implemented by Public International Organizations (PIOs) see also Annex 2.

This IEE addresses the following USAID/DRC Health Office activities:

1. Equity Afia

2. HIV Epidemic Control (HEC) Activity (DRC)

3. HIV Epidemic Control (HEC) Follow-On Activity – Lualaba (DRC)

4. Integrated Health Program (IHP) – (DRC)

5. Integrated HIV/AIDS Program (IHAP) – Haut Katanga (DRC)

6. Integrated HIV/AIDS Program (IHAP) – Haut Katanga Follow-On Activity

7. Integrated HIV/AIDS Program (IHAP) – Kinshasa (DRC)

8. Integrated HIV/AIDS Program (IHAP) – Kinshasa Follow-On Activity

9. Local Organizations Network (LON) Reduce TB Project (DRC)

10. LON SASA IVI DRC – Elimination of Tuberculosis Kasai/Eastern Congo

11. Local Partner Key Populations (KP) Program

12. Orphan and Vulnerable Children (OVC) ELIKIA Follow-On Activity (DRC)

13. President’s Malaria Initiative (PMI) Impact Malaria

14. TBD Cross Border HIV Epidemic Control (HEC)

15. USAID’s End Malaria Project (DRC) https://www.usaid.gov/our_work/environment/compliance/22cfr216 https://www.usaid.gov/ads/policy/200/201mal

HEALTH PORTFOLIO 2022 – 2027

1.3 ACTIVITY DESCRIPTION

The Intervention Categories analyzed across this document are to be undertaken by USAID/DRC under the most recent Country Development Cooperation Strategy (CDCS 2020- 2025). As a result of the CDCS’ multi-sectoral approach to achieve results in DRC’s challenging operational environment, the interventions listed within this IEE align with all three development objectives (DO) which include DO 1: Responsiveness of Public Institutions to Citizens’ Needs Improved, DO 2: Community Resilience Increased, and DO 3: Inclusive, Broad-Based, and Sustainable Economic Growth Increased.

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

ACTIONS

Intervention Category

Sub-interventions Illustrative Actions DRC Mission Activities3

Intervention Category 1:

Healthcare Provider Training:

Healthcare Workforce Strengthening & Development

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

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

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

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

● IHP

● LON

Reduce TB

● LON SASA

IVI

● OVC

ELIKIA

Follow-On

● PMI Impact Malaria

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

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

● Train parents and caregivers caring for children with HIV

● Strengthen the connections between health service personnel and communities

● HEC

● HEC

Lualaba Follow-On

● IHP

● LON

Reduce TB

● LON SASA

IVI

● OVC

ELIKIA

Follow-On

● TBD Cross Border

HEC

Intervention Category 2:

Procurement of Commodities & Strengthening of Commodities, Sub-intervention 2.1: Capacity building to support critical policy and strategy reforms to supply chain management

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

● IHP

3 This list may change. These changes have no incidence on the content of this IEE.

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions DRC Mission Activities3

Logistics & Diagnostic Systems

Sub-intervention 2.2: Improve commodity procurement and supply chain management strategies to ensure availability of health products

● Forecast and quantify national commodity needs and procure medicines and diagnostics

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

● Improve supply chain management, strengthen logistics management information systems, and support provincial health departments to improve the availability of medicines

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

● IHP

● LON SASI

IVI

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

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

● Increase the availability of quality, affordable contraceptive commodities

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

● Support community management and oversight of essential health commodities

● IHP

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

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

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

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

● Support the scale-up of high impact health interventions

● IHP

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

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

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

● Provide technical assistance in ongoing monitoring of quality assurance standards and governance-related business operation compliance as it relates

● Equity Afia

● IHP

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions DRC Mission Activities3 to health care service delivery and management

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

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

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

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

● IHP

● LON

Reduce TB

● LON SASA

IVI

Sub-intervention 3.4: Improve provision of and demand for quality HIV/AIDS health care services

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

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

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

● Improve efficiency of laboratory functions for more readily accessible diagnostics

● HEC

● HEC

Lualaba Follow-On

● IHAP-Haut Katanga

● IHAP-Haut Katanga Follow-On

● IHAP-

Kinshasa

● IHAP-

Kinshasa Follow-On

● IHAP-Haut Katanga

● Local Partner KP Program

● OVC

ELIKIA

Follow-On

● TBD Cross Border

HEC

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

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

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

● LON

Reduce TB

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions DRC Mission Activities3

Sub-intervention 4.2: Support community and private sector participation in SBC interventions

● Focus on community engagement to increase demand for HIV/AIDS services

● Support SBC activities to foster adoption of healthy behaviors

● Expand communications efforts to include vaccination and countering misinformation

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

● IHP

● IHAP-

Kinshasa

● IHAP-

Kinshasa Follow-On

● IHAP-Haut Katanga

● IHAP-Haut Katanga Follow-On

● Local Partner KP Program

● TBD Cross Border

HEC

Intervention Category 5: Policy and Strategy Development and Assistance

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

● Promote advocacy to advance key population rights in the DRC

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

● Local Partner KP Program

● LON

Reduce TB

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

● Support the Government of DRC in establishing policies that mitigate the HIV-epidemic impact

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

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

● HEC

● HEC

Lualaba Follow-On

● IHP

● TBD Cross

Border

HEC

Intervention Category 6:

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

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

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

● Provide technical assistance for biomarker data collection

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

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

● IHP

● PMI Impact

Malaria

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions DRC Mission Activities3 vectors and patterns of insecticide resistance

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

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

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

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

● LON SASI

IVI

● PMI Impact Malaria

Sub-intervention 6.3: Conduct demographic and health surveys

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

● LON SASI

IVI

Intervention Category 7:

Technical Assistance to Malaria Vector Control

Sub-intervention 7.1: Insecticidal- Treated Nets (ITN) Distribution

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

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

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

● IHP

● USAID’s

End Malaria

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

Sub-intervention 8.1: Construction of small-scale facilities and/or limited refurbishment at existing facilities

● Construction of new health facilities

● Support limited rehabilitation and/or expansion of health facilities

● Equity Afia

● IHP

Intervention Category 9:

Resource/ Financial Mobilization

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

● Distribute cash transfers to highly vulnerable households

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

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

● HEC

● HEC

Lualaba Follow-On

● Local Partner KP Program

HEALTH PORTFOLIO 2022 – 2027

Intervention Category

Sub-interventions Illustrative Actions DRC Mission Activities3

● OVC

ELIKIA

Follow-On

● TBD Cross Border

HEC

Sub-intervention 9.2: Improve budgeting and financial management systems

● Creation of a pooled insurance and financing model

● Equity Afia

Will this project/activity involve construction4 as defined by ADS 201 and 303? Yes ☒ No ☐

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

If yes, describe in the space below:

Small Scale Construction or Rehabilitation of Health Infrastructure (<10,000 sq. ft) https://www.usaid.gov/sites/default/files/documents/1865/201maw.pdf

HEALTH PORTFOLIO 2022 – 2027

2.0 BASELINE ENVIRONMENTAL INFORMATION

2.1 LOCATIONS AFFECTED AND ENVIRONMENTAL CONTEXT (ENVIRONMENT, PHYSICAL,

CLIMATE, SOCIAL, THREATENED AND ENDANGERED SPECIES)

Geography: DRC is in Central Africa and has a total land area of 2.34 million square kilometers (km), making it the second largest country in Sub-Saharan Africa and the 11th largest country in the world.5 With a short Atlantic coastline (37 km) in the west, DRC shares land borders with nine countries – Angola, Burundi, Central African Republic, Republic of Congo, Rwanda, South Sudan, Tanzania, Uganda, and Zambia. Most of the country is composed of the central Congo Basin, a vast low lying plain, surrounded by high plateaus to the north, west, and south. In the east are Lakes Albert, Edward, Kivu, Tanganyika, and Mweru as well as high mountain ranges, including the Mitumba Mountains (southeast), Ruwenzori Range, and the volcanic Virunga Mountains.6 The Congo River, including its 3.4 million square km basin, and tributaries provide the most extensive network of navigable waterways in Africa.

Climate: DRC’s vast territory is divided into three major climatic regions: (a) hot and humid climate in the equatorial river basin; (b) cooler, drier climate in the southern highlands; and (c) cooler and wetter climate in the eastern highlands.7 North of the Equator, the west season is April to October with a dry season in December to February. The wet and dry seasons are reserved south of the Equator, November to March and April to October, respectively.

Biodiversity: DRC is home to critical habitats supporting rich biodiversity, including 19 habitat types divided among four main ecosystems: forests, savannah-forest mosaic, afro-montane, and aquatic.8 Plant life is lush and varies between climate zones. With 62 percent of the Congo Basin lying within the country, DRC is host to a substantial portion of the world’s tropical forests and most critical wilderness areas.9 The Congo Basin contains 10,000 species of tropical plants, of which 30 percent are unique to the region. Four hundred mammal species, including endangered forest elephants, chimpanzees, bonobos, and lowland and mountain gorillas, are found in the Basin, as well as 1,000 species of birds and 700 species of fish.

DRC has five natural UNESCO World Heritage Sites: Garamba National Park, Kahuzi-Biega National Park, Okapi Wildlife Reserve, Salonga National Park, and Virunga National Park.

Virunga National Park, located in the center of the Albertine Rift in the Great Rift Valley, is especially unique, as it contains a range of biodiversity and habitats unparalleled in Africa. The Rwenzori and Virunga mountains are home to the two most active volcanoes in Africa and host a number of endemic, rare, and globally threatened species.

Several factors are driving the loss of wildlife and their habitats, including water pollution, deforestation, soil erosion, and mining. However, the leading cause of wildlife loss in the Congo Basin is the commercial bushmeat trade; monkeys and antelope are the main targets, but

5 Encyclopedia Britannica. 2021. “Democratic Republic of the Congo”. https://www.britannica.com/place/Democratic- Republic-of-the-Congo 6 Ibid.

7 CIA. 2021. “The World FactBook: DRC – Environment”. https://www.cia.gov/the-world-factbook/countries/congo-democratic-republic-of-the/#environment 8 USAID. 2018. “Tropical Forest and Biodiversity Assessment for Central African Regional Program for the Environment (CARPE) and the Democratic Republic of Congo (DRC)”.https://pdf.usaid.gov/pdf_docs/PA00T96P.pdf 9 USAID. 2018. “Climate Risk Profile: Democratic Republic of Congo”.

https://www.climatelinks.org/sites/default/files/asset/document/20180716_USAID-ATLAS_Climate-Risk- Profile_DRC.pdf https://www.britannica.com/place/Democratic-Republic-of-the-Congo https://www.britannica.com/place/Democratic-Republic-of-the-Congo https://www.cia.gov/the-world-factbook/countries/congo-democratic-republic-of-the/#environment https://www.cia.gov/the-world-factbook/countries/congo-democratic-republic-of-the/#environment https://pdf.usaid.gov/pdf_docs/PA00T96P.pdf https://www.climatelinks.org/sites/default/files/asset/document/20180716_USAID-ATLAS_Climate-Risk-Profile_DRC.pdf https://www.climatelinks.org/sites/default/files/asset/document/20180716_USAID-ATLAS_Climate-Risk-Profile_DRC.pdf

HEALTH PORTFOLIO 2022 – 2027

gorillas and bonobos are also at risk.10 Over a million tons of bushmeat is consumed in the DRC every year and in rural areas, bushmeat can be the primary income source for families, as well as the only profitable export. In addition, the international demand for ivory continues to drive the killing of protected elephants.

Demographics & Society: The DRC has a population of approximately 92.4 million people (2021, UNFPA), half of whom live in rural areas, mostly in scattered villages. The Congolese are ethnically diverse with more than 200 African ethnic groups living in the DRC of which the majority are Bantu; the four largest tribes – Mongo, Luba, Kongo (all Bantu), and the Mangbetu- Azande (Hamitic) – make up about 45% of the population.11 DRC’s rate of population growth, though amongst the world’s highest, is comparable to other African countries, estimated at 3.2 percent per year.12 As in most African countries, DRC’s population is young with more than two-fifths of the population under 15 years of age and almost three-fourths under 30.

Despite fertile land, rich biodiversity, and vast quantities of natural resources and minerals, DRC is currently characterized by significant social vulnerability, political instability, food insecurity and high poverty rates. DRC has faced civil war and conflict over control of its natural resources for most of the past three decades. Tantalum, tungsten, tin, and gold are all found abundantly within DRC, and are used in electronic devices. Eastern DRC has been an active conflict zone on and off since 1996. Traditional ethnic hostilities have also been exacerbated by an influx of small arms into the area. Further, lack of economic opportunity attracts youth to armed forces and local militias that have become criminal gangs. DRC is a source and host country for refugees – an estimated 3.9 million Congolese were internally displaced as of October 2017, the vast majority fleeing violence between rebel groups and Congolese armed forces. Moreover, thousands of refugees have come to the DRC from neighboring countries, including Burundi, Central African Republic, and Rwanda.

DRC’s ecosystems have also faced the burden of ongoing conflict. Both Congolese refugees and rebels take shelter in the forests: mining, clearing forest tracts, and hunting bushmeat for subsistence.13 War has also led to a prioritization of resources that has destabilized national park management. Wildlife and their habitats are vulnerable to mining and harvesting by poachers, and new roads lead to mining sites in forests that were previously impenetrable, leading to environmental destruction from hunters, loggers, and miners.

The Peace, Security, and Cooperation Framework for the DRC, signed in Addis Ababa in 2013, is a promising sign that peace prospects are more likely, but many previous peace agreements have been implemented with no lasting impact, and the conflict continues. Transitioning to a stable democracy will be a challenge in a country where political processes are often considered untrustworthy, non-inclusive, and lacking leadership.

Health Profile: Despite the protracted civil war that had devastating effects on health care standards in DRC, considerable progress has been made against ongoing significant health

10 USAID. 2018. “Tropical Forest and Biodiversity Assessment for Central African Regional Program for the Environment (CARPE) and the Democratic Republic of Congo (DRC)”.https://pdf.usaid.gov/pdf_docs/PA00T96P.pdf 11 Encyclopedia Britannica. 2021. “Democratic Republic of the Congo”. https://www.britannica.com/place/Democratic- Republic-of-the-Congo 12 CIA. 2021. “The World FactBook: DRC – People and Society”. https://www.cia.gov/the-world-factbook/countries/congo-democratic-republic-of-the/#people-and-society 13 USAID. 2018. “Tropical Forest and Biodiversity Assessment for Central African Regional Program for the Environment (CARPE) and the Democratic Republic of Congo (DRC)”.https://pdf.usaid.gov/pdf_docs/PA00T96P.pdf https://pdf.usaid.gov/pdf_docs/PA00T96P.pdf https://www.britannica.com/place/Democratic-Republic-of-the-Congo https://www.britannica.com/place/Democratic-Republic-of-the-Congo https://www.cia.gov/the-world-factbook/countries/congo-democratic-republic-of-the/#people-and-society https://www.cia.gov/the-world-factbook/countries/congo-democratic-republic-of-the/#people-and-society https://pdf.usaid.gov/pdf_docs/PA00T96P.pdf

HEALTH PORTFOLIO 2022 – 2027

challenges, including communicable and noncommunicable diseases.14 Improved leadership and investments in priority health issues by the DRC Government and international partners have strengthened the DRC’s health system but critical improvements to infrastructure for health service delivery are still needed.15 DRC’s average life expectancy (61 years; 2019) is among the lowest in the world, but comparable to that of other Sub-Saharan African countries.16

Infant/Child Mortality: Even with steady declines since 1990, mortality rates among infants under one year and children under five years are among the highest in the world at 64 deaths per 1,000 live births and 81.2 deaths per 1,000 live births (2019), respectively.17 Infectious diseases

– including malaria, tuberculosis, and lower respiratory infections –significantly contribute to the top causes of infant/child mortality.18

Maternal Health: The maternal mortality ratio (MMR) is estimated at 473 deaths per 100,000 live births (2017) and has steadily declined since 2000 but is comparable to regional countries.19 While 85 percent of deliveries are attended by skilled health personnel, rates of antenatal and postnatal care remain low. Additionally, DRCs fertility rate is among the world’s highest, averaging around five children per woman.20

Water, Sanitation & Hygiene: Access to clean water and improved sanitation remain a challenge throughout much of DRC. Only half of the population have access to improved water supply and only 29% have improved sanitation facilities.21 Approximately 33 million people living in rural areas do not have access to quality water which plays a role in high chronic malnutrition rates and transmission of waterborne diseases.22

Malnutrition: The food security situation in DRC has been problematic for several years due to conflict, epidemics, and other facts.23 In 2017, 7.7 million people were experiencing acute food insecurity, with that number projected to be between 7.5 million and 10 million in 2021.

Approximately two million children in DRC are suffering from severe acute malnutrition (SAM), accounting for 12 percent of SAM cases worldwide.24 Although malnutrition is a national challenge, it is more pronounced amongst those living in the greater Kasai region and the eastern provinces of North Kivu, South Kivu, and Tanganyika.

14 Encyclopedia Britannica. 2021. “Democratic Republic of the Congo”. https://www.britannica.com/place/Democratic- Republic-of-the-Congo 15 USAID. 2021. “DRC – Global Health”. https://www.usaid.gov/democratic-republic-congo/global-health 16 The World Bank. 2019. Life expectancy at birth, total (years). https://data.worldbank.org/indicator/SP.DYN.LE00.IN 17 UNICEF. 2019. “DRC– Demographics, Health & Infant Mortality”. https://data.unicef.org/country/cod/ 18 Institute for Health Metrics and Evaluation. 2019. Global Burden of Disease (GBD) – DRC.

https://vizhub.healthdata.org/gbd-compare/ 19 UNICEF. 2019. “DRC– Demographics, Health & Infant Mortality”. https://data.unicef.org/country/cod/ 20 CIA. 2021. “The World FactBook: DRC – People and Society”. https://www.cia.gov/the-world-factbook/countries/congo-democratic-republic-of-the/#people-and-society 21 UNICEF. 2018. WASH situation in DRC. Retrieved from https://www.unicef.org/drcongo/en/what-we-do/water-sanitation-and-hygiene 22 Ibid.

23 USAID. 2021. “Democratic Republic of the Congo: Nutrition Profile”.

https://www.usaid.gov/sites/default/files/documents/tagged_DRC-Nutrition-Profile.pdf 24 Ibid.

https://www.britannica.com/place/Democratic-Republic-of-the-Congo https://www.britannica.com/place/Democratic-Republic-of-the-Congo https://www.usaid.gov/democratic-republic-congo/global-health https://data.worldbank.org/indicator/SP.DYN.LE00.IN?most_recent_value_desc=false https://data.unicef.org/country/cod/ https://vizhub.healthdata.org/gbd-compare/ https://data.unicef.org/country/cod/ https://www.cia.gov/the-world-factbook/countries/congo-democratic-republic-of-the/#people-and-society https://www.cia.gov/the-world-factbook/countries/congo-democratic-republic-of-the/#people-and-society https://www.unicef.org/drcongo/en/what-we-do/water-sanitation-and-hygiene https://www.unicef.org/drcongo/en/what-we-do/water-sanitation-and-hygiene https://www.usaid.gov/sites/default/files/documents/tagged_DRC-Nutrition-Profile.pdf

HEALTH PORTFOLIO 2022 – 2027

Major Infectious Diseases: Among the leading causes of deaths in DRC are malaria, tuberculosis (TB), respiratory infections, diarrheal diseases, and HIV/AIDS.25 Malaria is considered DRC’s most important public health problem as the DRC has the second highest number of malaria cases and deaths globally – 12% and 11% (2020), respectively.26 Similarly, DRC has high rates of TB, including multi-drug resistant TB, with TB/HIV co-infection presenting a major health challenge in the DRC.27 Among the top 30 high TB burden countries, the estimated TB incidence for DRC has remained around 300 per 100,000; however, the number of TB cases notified has recently increased, highlighting persistence challenges in TB case detections/notifications.28 Approximately, 520,000 adults and children are living with HIV/AIDS in DRC (2020).29 In addition, measles, leprosy, African trypanosomiasis (i.e., sleeping sickness), bubonic plague, and hemorrhagic fevers (e.g., Ebola) remain endemic in many parts of the country. However, DRC has been free of wild poliovirus since 2000, a major achievement given the country’s size and health system.30

2.2 APPLICABLE AND APPROPRIATE PARTNER COUNTRY AND OTHER INTERNATIONAL

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

DRC has produced and adopted a range of environmental policies, strategic plans, and legislation, and is party to several international environment and climate agreements.31

Applicable National Policies, Laws, and Regulations include:

Constitution: Adopted in 2006 and amended in 2011, it states that every person has a right to a healthy environment, that the environment must be protected, and that the state is responsible for protecting the environment and the health of the people (Article 53). Further, Article 123 makes provisions for laws to be made concerning the protection of the environment and tourism and Article 203 calls for cooperative governance between central and provincial administration to protect and conserve the environment, natural sites, and landscapes.

Fundamental Principles Relating to Environmental Protection (Law No.11/009): This law sets out the fundamental principles of environmental protection and establishes the institutional framework as well as the procedural and financing mechanisms for environmental protection.

Additionally, it establishes the rules for the management and conservation of natural resources, including the regulation of civil liability. It also requires Environmental and Social Impact Assessments (ESIA) for projects; environmental audits; environmental evaluation of policies, plans, and programs; the creation of new institutional structures; and an Environmental Fund for research, conservation, clean-up operations, rehabilitation, and pollution prevention.

25 Institute for Health Metrics and Evaluation. 2019. Global Burden of Disease (GBD) – DRC.

https://vizhub.healthdata.org/gbd-compare/ 26 WHO. 2020. World Malaria Report 2020. https://www.who.int/publications/i/item/9789240015791 27 WHO. 2020. Democratic Republic of Congo (DRC) – Integrating tuberculosis screening into community-based HIV activities. https://www.who.int/publications/m/item/democratic-republic-of-the-congo-integrating-tuberculosis-screening-into-community-based-hiv-activities 28 USAID. 2021. DRC TB Roadmap Overview, Fiscal Year 2021.

https://www.usaid.gov/sites/default/files/documents/DRC_Narrative_TBRM21_TB_DIAH_Version_FINAL.pdf 29 UNAIDS. 2020. DRC. https://www.unaids.org/en/regionscountries/countries/democraticrepublicofthecongo 30 Global Polio Eradication Initiative. n.d. Polio-Free Countries. https://polioeradication.org/where-we-work/polio-free-countries/ 31 Food and Agriculture Organization of the United Nations (FAO). n.d. Democratic Republic of the Congo - Country Profiles. https://www.fao.org/faolex/country-profiles/general-profile/en/?iso3=COD https://vizhub.healthdata.org/gbd-compare/ https://www.who.int/publications/i/item/9789240015791 https://www.who.int/publications/m/item/democratic-republic-of-the-congo-integrating-tuberculosis-screening-into-community-based-hiv-activities https://www.who.int/publications/m/item/democratic-republic-of-the-congo-integrating-tuberculosis-screening-into-community-based-hiv-activities https://www.usaid.gov/sites/default/files/documents/DRC_Narrative_TBRM21_TB_DIAH_Version_FINAL.pdf https://www.unaids.org/en/regionscountries/countries/democraticrepublicofthecongo https://polioeradication.org/where-we-work/polio-free-countries/ https://polioeradication.org/where-we-work/polio-free-countries/ https://www.fao.org/faolex/country-profiles/general-profile/en/?iso3=COD

HEALTH PORTFOLIO 2022 – 2027

Nature Conservation Law (Law No. 14/003): Establishes the rules relating to the conservation of biological diversity, the sustainable use of its constituent elements, and the access and fair and equitable sharing of benefits arising from the use of biological and genetic resources. It contributes to ensuring the conservation of ecosystems and natural habitats, the protection of species of wild fauna and flora as well as sustainable development in protected areas.

Other Relevant Legislation:

● Operating Rules of the Procedural Mechanisms for Environmental Protection (Decree No. 14-019)

● Forest Code (Law No. 11-2002)

● Public Hygiene and Sanitation (Ordinance 71-18)

Applicable National Strategic Plans include:

National Strategic Plan for Family Planning (2014-2020): The main objectives of this plan are to increase modern contraceptive prevalence, estimated at 6.5% in 2013, to at least 19.0% by 2020; and ensure access to and use of modern contraceptive methods to at least 2.1 million additional women by 2020.

DRC National Health Development Plan (NHDP) (2011-2015): The NHDP is a comprehensive plan that covers major causes of mortality and morbidity in the country. The main objectives of the NHDP are moving toward sustainable health systems and health care services, by making the health zone network the key implementation unit and increasing health zone program efficiencies, effectiveness, and mutual accountability.

National Health System Strengthening Strategy (2006): The purpose of this strategy intends to reorganize the health system in order to increase access to quality health care.

National Strategy Against Gender-based Violence (NSGBV) (2009): The objectives of this strategy are to reduce impunity for perpetrators of SGBV, increase prevention of and protection against SGBV for vulnerable populations, improve the capacity of the security sector to address SGBV, and- increase access to quality services for survivors of SGBV.

National Action Plan 1325 (NAP 1325) (2017-2021): This action plan pursues 11 specific objectives drawn from Resolution 1325 and is aligned with the New Deal, the guidelines of the international framework of the findings of the African Union Agenda on women, peace and security, African Union Agenda 2063 and the SDOs to which it is linked, the expected results, the activity to be undertaken with their intervening actors and the key indicators for measuring change.

National Sanitation Development Plan (2017-2021): This plan aims to eliminate open defecation and provide 100 percent access to basic sanitation by 2021, Decree No. 15/042 of 16 December 2015 on the creation, organization and functioning of the National Multisectoral Committee on Nutrition: The cnmn-DRC aims to: define the ways and means of implementing the National Multisectoral Nutrition Policy; develop, implement and monitor the implementation of the National Strategic Plan for Nutrition; ensure the coordination of Nutrition actions in the Democratic Republic of Congo.

HEALTH PORTFOLIO 2022 – 2027

National Protocol for Integrated Management of Acute Malnutrition (PCIMA) (2012): The approach to the implementation of CIMA recommends observing the following: (i) the integration of CIMA at all levels of the health system and the definition of the role of each structure; (ii) the overall implementation of all management components and units in a coordinated and synergistic manner to ensure the continuum of care; (iii) phased implementation in all provinces, health districts, health zones and health areas of the country; (iv) community participation; (v) encouraging teamwork at all levels of the health system; and (vi) intra- and cross-sectoral collaboration.

National Nutrition Program (PRONANUT) (2011-2015): The objective of the Programme is to ensure quality nutritional care for the entire population, especially children, women, including people living with HIV.

National Biodiversity Strategy and Action Plan (2016-2020): Based on the recommendations made…