J.5_Health_IEE_with_BEO_approved_page_Sept_28_2012.doc

DCN: Asia 12-213 Approved 9/28/12

ENVIRONMENTAL COMPLIANCE FACESHEET FOR THE

INITIAL ENVIRONMENTAL EXAMINATION (IEE)

Objective:

Objective 3/ Investing in People

Program Areas:

3.1 Health

Program Elements:

3.1.1 HIV, 3.1.2 Tuberculosis, 3.1.5 Other Public Health Threats, 3.1.6 Maternal and Child Health, 3.1.7 Family Planning and Reproductive Health Country/Region:

Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan Funding Period:

FY2012 – FY2016

Resource Levels/Amount(s):

Estimated $94 million Statement Prepared by:

Jesse Joseph, Health Officer, Health and Education Office, USAID/CAR Date:

September 15, 2012 IEE Amendment? Yes No FORMCHECKBOX

Environmental Media and/or Human Health Potentially Impacted (check all that apply):

None FORMCHECKBOX

Air FORMCHECKBOX

Water FORMCHECKBOX Land FORMCHECKBOX Biodiversity FORMCHECKBOX Human health FORMCHECKBOX Other FORMCHECKBOX

Environmental Action(s) Recommended (check all that apply):

FORMCHECKBOX

Categorical Exclusion(s)

FORMCHECKBOX

Initial Environmental Examination:

FORMCHECKBOX

Negative Determination: no significant adverse effects expected regarding the proposed activities, which are well defined over life of activity. IEE prepared:

FORMCHECKBOX

With conditions: no special mitigation measures needed; normal good practices will be used. For the possible limited procurement of equipment, the proposed action is that the implementer is required to ensure that equipment, commodities (also see ADS 312) and materials are procured from certified retailers; environmental safety and quality certificates conforming with national and/or international standards are available; equipment and materials are used in an environmentally sound and safe manner, properly disposed of when applicable at the end of their useful life in a manner consistent with best management practices according to USG, European Union or equivalent standards acceptable to USAID (see Facesheet Table 2 and IEE Section 4).

FORMCHECKBOX

With conditions (special mitigation measures specified to prevent unintended impact for activities listed in Facesheet Table 2 and IEE Section 4).

Summary of Findings:

The purpose of this document is to review current and planned activities covered under Objective 3: Investing in People (program elements 3.1.1 HIV, 3.1.2 Tuberculosis, 3.1.5 Other Public Health Threats, 3.1.6 Maternal and Child Health, 3.1.7 Family Planning and Reproductive Health) in the period 2012-2016 by the Health Offices of USAID /CAR and USAID/Kyrgyzstan. Until now, on-going programs have been covered by the umbrella Amendment #2 to the Initial Environmental Examination (IEE) “DCN: 2007-CAR-003”, signed by Bureau Environmental officer (BEO) on 9/3/2002 and valid through September 30, 2012; Phase IEE (DCN: 2008-Taj-001) signed on 7/11/2008 and expired on September 9/30/2010; and MCH and Tajikistan Safe Drinking Water Project (DCN: Asia 09-157), signed by BEO on 30/09/09 which expire on 9/30/2012. This new IEE fully supersedes the existing IEE Amendment #2 for all health activities from 2012 to 2016 and reflects changes in budget, activities, and length of projects.

The following current and planned projects, and illustrative activities, are to be implemented with health funding during FY2012 - FY2016, under the USAID/CAR Program Area 3.1, Health (Table 1).

Table 1. General Activities in the Health Portfolio Objective 3: Investing in People Program Area: 3.1 Health

3.1.1, 3.1.2, 3.1.5, 3.1.6,

3.1.7 Quality Health Care Project

Abt. Associates

LOP: 09/2010 – 09/2015

LOP Budget: $72,000,000

Countries: Kz, Kg, Tj, Tx, Uz;

The Quality Health Care Project aims to improve health outcomes by providing trainings and technical assistance focused on HIV/AIDS, tuberculosis, family planning and reproductive health, and maternal and child health to Ministries of Health, NGOs and CSOs. The project has small construction/ renovation activities of health care facilities and procurement of office and laboratory equipment such as Xpert MTB/RIF, a cartridge-based, automated diagnostic test.

PSI

LOP: 09/30/2009-09/29/2014

LOP Budget: $22,000,000

Countries: Kz, Kg, Tj, Tx, Uz The Dialogue on HIV and TB project provides technical assistance, trainings and direct outreach services to increase access to quality HIV prevention and TB prevention and treatment services for most-at-risk-populations. Activities may include small construction activities and procurement of laboratory equipment.

WHO

LOP: 2010-2013

LOP Budget: $475,000

Countries: Kz, Tj, Uz The WHO Polio Grant provides technical assistance for polio immunization campaigns and improved country surveillance for potential communicable diseases, through trainings and workshops.

WHO

LOP: 2012-2015

LOP Budget: $3,500,000

Countries: Tx, Uz The WHO PIO Grant will support technical assistance and trainings to the Uzbek and Turkmen national responses to tuberculosis. Its objectives are to:

1.Strengthen National TB Control Program management, coordination, monitoring and evaluation

2. Strengthen the quality of implementation of Stop TB Strategy plus nationwide.

1. Kazakhstan Association on Sexual and Reproductive Health/

2. Women's League of Creative Initiatives

LOP: 2012 – 2014

LOP Budget: $100,000 ($50,000 each)

Countries: Kz

1. Increase access to family planning services and accurate information for families and youth, and upgraded skills and access to evidence-based practices for providers through regional education centers

2. To improve nutrition and feeding for institutionalized children under four years of age in Kazakhstan.

LOP: 2009-2012

LOP Budget: $450,000

Country: Tx The goal of this project is to reduce the initiation of young people into behaviors which can lead to crime, drug use, poor health, and HIV infection by supporting two youth centers and one drop-in center which provide vulnerable youth with health education and referrals to medical services.

Note: Kg - Kyrgyzstan, Tj -Tajikistan, Tx –Turkmenistan, Kz- Kazakhstan, Uz – Uzbekistan It is anticipated that in various projects the following activities may take place: procurement of electric and electronic equipment including computers, electronic devices; small-scale construction or minor renovation activities related to sanitation and hygiene and drinking water supply. All of these activities will require monitoring and screening and application of various mitigation measures as described in IEE Table 2 (IEE Section 4).

Table 2 presents results of environmental screening and recommends threshold determinations for the main types of activities under all program elements.

Table 2. Proposed Health Activities, Recommended Threshold Decisions and required Reg.216 actions

All Program activities expected to have no effect on the natural or physical environment This includes: education, technical assistance, training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.); consultations, participant training, document transfers and information dissemination, analysis, studies, conferences workshops, study tours, curriculum development, working with training programs, developing information networks

While these activities are considered to have no impact on the environment, environmental health and quality considerations should be incorporated into all relevant steps along the healthcare continuum, as part of quality assurance and infection prevention approaches.

See IEE Tables 1 and 2 for more details.

No special mitigation measures are needed; activities are implemented with conditions that normal good practices, engineering methods and standard instructions are followed.

This includes procurement of office furniture, electric and electronic equipment and materials (no bio-hazardous or low-radiological materials will be used for testing in this equipment).

Insignificant effect

Negative Determination with conditions. The implementer is required to ensure that equipment, commodities (also see ADS 312) and materials are procured from certified retailers; environmental safety and quality certificates conforming with national and/or international standards are available; equipment and materials are used in an environmentally sound and safe manner, properly disposed of when applicable at the end of their useful life in a manner consistent with best management practices according to USG, European Union or equivalent standards acceptable to USAID.

See IEE Tables 1 and 2 for more details.

Examples include:

- Medical laboratories and centers upgrade; equipment procurement and installation; HIV and TB testing;

- Procurement and use of medical kits, supplies, and chemical reagents;

- Procurement and use of pharmaceutical drugs;

-Immunization campaigns including TA and vaccination;

-Small-scale construction/renovation of sanitation and health facilities;

- Small-scale water supply and water quality improvement activities (may include application of disinfectants that are registered as pesticides);

- Improved nutrition and feeding; and

- Generation, storage and disposal of hazardous wastes as part of various activities;

Potential for a significant adverse effect of one or more activities

Negative Determination with conditions;

EDD in form of Environmental Review and Assessment Checklist (IEE Annex 1) is required to identify environmental effects, develop Environmental Manual and Mitigation and Monitoring Plans when applicable, confirm /neglect and mitigate a potentially significant adverse effect. If significant adverse effects are expected, a Scoping Statement (SS) and Environmental Assessment (EA) shall be conducted by the implementer prior to start of activities. SOW/Terms of Reference (TOR) for Scoping Statement and EA Report must be reviewed by Mission Environmental Officer (MEO) and approved by Asia BEO.

For details, please see Section “Implementer Procedures” and IEE Section 4.

Note: EDD - Environmental Due Diligence Review

USAID/CAR’s Health portfolio is primarily technical assistance focusing on improving the quality of service delivery, government and NGO capacity building, and institutional strengthening, and is not expected to have a negative impact on the environment. The overall environmental determination for 90% of USAID/CAR health programming is Categorical Exclusion for activities that were found to present no risk according to 22 CFR 216 guidelines, and is Negative Determination with conditions for the remaining 10%.

a) Recommended Action: Categorical Exclusion (90% of funding)

Pursuant to 22 CFR 216.2(c)(2)(i), the originator of the activities has determined that all of the activities consist of types of interventions entirely within the categories listed in paragraph (c)(2), “Categorical Exclusions,” of Section 216.2, “Applicability of Procedures,” of Title 22 CFR Part 216, “AID Environmental Procedures”, and therefore are categorically excluded from further environmental review requirements. The originator of the proposed action has further determined that the proposed activities are fully within the following classes of actions:

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

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

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

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

b) Recommended Action: Pursuant to 22 CFR216.3(a)(2)(iii), a Negative Determination with conditions (10% of funding) is recommended for any Health Care activities that have potential for adverse impact on the environment in the following categories, as presented in Section III of Table 2 of this document:

a. Procurement, storage, management and disposal of public health commodities, including pharmaceutical drugs, medical kits, supplies and chemical reagents;

b. Generation, storage and disposal of hazardous or highly hazardous medical waste, e.g. HIV testing, TB testing and laboratory-related activities;

c. Small-scale construction/rehabilitation of health facilities;

d. Small-scale water and water quality assurance activities;

e. Immunization campaigns (might include procurement of vaccine and its administration thereof, storage, distribution, and waste disposal); and

f. Improved nutrition and feeding

For each type of these activities an implementer will conduct Environmental Due Diligence (EDD) as part of the Environmental Review and Assessment Checklist (Annex 1) to document existing environmental concerns and foreseeable environmental effects resulting from the activity and develop an Environmental Manual (EM) and Framework Environmental Mitigation and Monitoring Plan (FEMMP) when applicable. This EM and FEMMP will then be approved by the MEO, in consultation with the Asia & OAPA Regional Environmental Advisor (REA), adapted to a specific site before the activity implementation (site specific EMMP), and incorporated into the project design. The Standard Conditions List in Annex 3 and IEE Table 2 of this IEE may be used as a guide in developing of EM, FEMMP, and EMMP along with other references listed in Implementer Procedures section.

Implementer Procedures:

The implementing partner will employ the following process for all relevant activities:

· All program activities will seek to raise environmental awareness, promote regional and national environmentally and socially sustainable development, biodiversity conservation, adaptation to climate change, foster the culture of environmental compliance and governance, in accordance with The UNECE Aarhus Convention on Access to Information, Public Participation in Decision-making and Access to Justice in Environmental Matters with reference to it: http://www.unece.org/env/pp/welcome.html

· The implementer will include environment compliance considerations into all aspects of the program implementation and will promote and train local counterparts on environmental requirements and standards across all of the program’s activities. Such proposed activities will be included into annual work plans, and results will be reported in annual reports.

· Each activity should be conducted in a manner consistent with good design and implementation practices described in USAID Environmental Guidelines for Small-Scale Activities in Africa, 2nd edition as provided at: http://www.encapafrica.org/egssaa.htm; IFC Environmental, Health and Safety Guidelines as provided at: http://www.ifc.org/ifcext/sustainability.nsf/Content/EnvironmentalGuidelines; World Health Organization guidelines as provided at http://www.who.int/publications/guidelines/environmental_health/en/index.html;

and Standard Conditions for Small-Scale Construction, Small-Scale Road Rehabilitation, Small- Scale Water and Wastewater Activities, attached to this IEE (Annex 3).

· Based on EDD results and mitigation measures from Environmental Guidelines for small-scale Activities, IFC EHS Guidelines, World Bank PPAH, and other documents as referenced above, implementer will develop Program Environmental Manual (EM) and Framework Environmental Mitigation and Monitoring Plan (FEMMP) for activities that may have negative environmental impact. EM will establish criteria for eligibility, selection and screening against potential environmental risk (low, moderate, and high). An EM and FEMMP might be done per implementing partner or the whole program and then adapted as needed for different implementing partners. This documentation will then be approved by the MEO, in consultation with the Regional Environmental Advisor for Asia (REA/Asia), incorporated in project design and FEMMP will be adapted to a specific site prior to the activity implementation (EMMP) (see IEE Annex 4).

· The implementer will use the Environmental Review and Assessment Checklist (ER Checklist) (IEE Annex 1) and Leopold Matrix (IEE Annex 2) as the main reporting documents for each activity having an adverse environmental impact.

· Prior to the launch of each activity including small grants and subcontracts, the implementer will conduct an Environmental Due Diligence (EDD) review as an inherent part of the ER Checklist for each activity that may have a potential for moderate and high adverse environmental impact (e.g. small-scale construction;, rehabilitation of potable water and sanitation facilities; etc.) to document existing environmental concerns and foreseeable environmental effects resulting from such types of activities. If the EDD results in a finding of potential significant environmental impact, a Scoping Statement (SS) and Environmental Assessment (EA) will be done by the implementer prior to start of activities. TOR for Scoping Statement, Scoping Statement and EA Report must be reviewed by MEO and approved by Asia BEO.

· As part of its initial Work Plan, and all Annual Work Plans thereafter, the implementer, in collaboration with the USAID Agreement/Contracting Officer’s Representative (A/COR) and MEO shall review all ongoing and planned activities under this award to determine if they are within the scope of the approved IEE; and classify them in accordance with Table 2 and IEE Section 3.

· When appropriate, the implementer will have a qualified, MEO-approved environmental impact professional(s) (EIP) who will assess and recommend environmental actions to be taken by the program and will coordinate implementation of mitigation measures, monitoring, and reporting. Specifically, the EIP will conduct environmental reviews and will identify: 1) activity category in consultation with the MEO; 2) potential environmental impacts (based on ER Checklist, EDD, Leopold Matrix, and his/her technical knowledge of the local, U.S., and international environmental standards, guidelines, requirements, and practices; and 3) mitigation and monitoring measures needed. Should the EIP lack special technical knowledge to identify any special environmental impact, the implementer will consult with a specialist in the relevant area.

· Documenting environmental baseline conditions prior to activity implementation is an integral part of the site specific EMMP.

· Host country laws and regulations for environmental protection and management will be followed in implementing the activities. For activities categorized as “potential risks”' or “definite risks” of adverse environmental impact, the implementing partner will be required to obtain a letter from the local or regional office for environmental protection stating that the office: a) has been contacted by the implementing partner concerning the project activities; b) will maintain contact with the project; and c) will be aware of the potential environmental impacts of the project to help ensure that no detrimental impact will result from this project.

· For such activities prior to their implementation the implementer will conduct public consultations and will seek concurrence from the national duly authorized environmental agency on FEMMPs and EMMPs.

· In all cases, implementation will adhere to corresponding host country environmental laws and policies, generally outlined in national Ministry of Health “SanPin” (Sanitary Epidemiological, or СанПиН) documents. The following are links to SanPin documents available online:

· Kazakhstan: http://www.mz.gov.kz/index.php?wakka=Rus/SanitarnoJepidemiologicheskijjNadzor/NPACT/Infonpa&v=u5e

· Kyrgyzstan: http://www.med.kg/Articles/ViewSection.aspx?ArticleID=230

· Uzbekistan: http://www.minzdrav.uz/documentation/list.php?SECTION_ID=141

· Monitoring will be conducted during the project (beginning with a baseline) to determine the environmental impact (positive and/or negative) of all project activities. The implementer shall use only qualified staff for overseeing the mitigation and monitoring work. Monitoring shall occur on an as-needed basis. The implementer will ensure that the environmental procedures are implemented, potential impacts mitigated, and indirect and cumulative effects are considered for each activity. If negative environmental impacts are discovered through regular monitoring and evaluation of project activities, immediate actions will be taken to rectify the situation.

· The implementer shall have sufficient resources and permanent staff with expertise in an environmental field and compliance with Reg. 216.

Resource Allocation, Training and Reporting requirements:

· The agreement/contract with the implementing partner will include environmental compliance and reporting language into agreements/contracts, and ensure that appropriate resources, staff, equipment and reporting procedures are dedicated to this portion of the project; the language will have a requirement to follow all recommendations of this IEE, including completed Environmental Review and Assessment Checklist, and EM and FEMMP, site specific mitigation and monitoring plans, and mitigation and monitoring reports. Reports will be submitted to the Agreement/Contracting Officer’s Representative (A/COR) and MEO prior to and at the completion of each relevant activity at every affected project site, and not at the end of the project or not on a semi-annual or annual basis.

· Sub-contracts or grants from the implementing partner to other organizations must incorporate provisions stipulating compliance with 22 CFR 216 and ADS 204.

· The A/COR of each project, in consultation with the MEO or REA and corresponding implementing partner(s), will actively monitor and evaluate whether environmental consequences not foreseen by this IEE arise during implementation, and will modify or halt activities as appropriate. If additional activities are added to a project but are not described in this IEE, an amended IEE must be prepared.

· When deemed necessary by the A/COR and MEO, reporting will include photographic documentation and site visit reports which fully document that all proposed mitigation procedures were followed throughout implementation of the subject work including quantification of mitigation.

· The implementer’s quarterly reports to USAID shall contain a section specific to Environmental Compliance will include project summaries along with environmental impacts, success or failure of mitigation measures being implemented, results of environmental monitoring, and any major modifications/revisions to the project, mitigation measures or monitoring procedures. If the activities implemented do not have any negative impact on the environment, this should be documented as well. The implementer’s annual report will include an annex containing a table indicating the title, date of award, and category of each grant activity.

· A/CORs together with MEO/Deputy MEO will explain all environmental conditions to the implementers at the post-award conference. The Mission will also arrange for Environmental Compliance Training for the implementer(s) by the MEO prior to the start of the project implementation.

Limitations of the IEE:

1. All reagents, disinfectants and other chemicals, registered by US EPA, as pesticides shall be procured, used or recommended for use only in accordance with BEO-approved Programmatic Pesticide Evaluation Report and Safe use Action Plans (PERSUAPs) for Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. If any additional chemicals are proposed, relevant Programmatic PERSUAPs shall be amended and approved by the BEO/Asia. The IEE shall be amended to reflect on the recommendations of the Programmatic PERSUAP, and approved by the BEO/Asia. For Kazakhstan, the implementer will request the BEO/Asia approval to extend validity of relevant CAR Programmatic PERSUAP sections to stipulate compliance with relevant Kazakhstan legislation.

2. No procurement, use or recommendation for use of ammonium nitrate (AN) and calcium nitrate (CAN) fertilizers.

3. No procurement or use of Asbestos Containing Materials (ACM) (i.e. piping, roofing, etc), Polychlorinated Biphenyl’s (PCB) or other toxic/hazardous materials prohibited by US EPA including lead or mercury containing materials as provided at: http://www.epa.gov/asbestos and/or under international environmental agreements and conventions, e.g. Stockholm Convention on Persistent Organic Pollutants as provided at: http://chm.pops.int.

4. This IEE does not cover activities involving:

a. support to wood processing, agro-processing, industrial enterprises, and regulatory permitting;

b. assistance, procurement or use of genetically modified organisms (GMOs), which would require preparation of biosafety assessment (review) in accordance with ADS 201.3.12.2(b) in an amendment to the IEE approved by Asia BEO; or

c. DCA or GDA programs.

Any of these actions would require an amendment to the IEE duly approved by Asia BEO.

Revisions:

Pursuant to 22CFR216.3(a)(9), if new information becomes available which indicates that activities to be funded by the project might be “major” and the project’s effect “significant,” this negative determination will be reviewed and revised by the originator of the project and submitted to the Bureau Environmental Officer for approval and, if appropriate, an environmental assessment will be prepared.

USAID APPROVAL OF ENVIRONMENTAL ACTION(S) RECOMMENDED:

Clearance:

Regional Mission Director:

Date: ________

Erin Elizabeth McKee Kyrgyzstan USAID Representative: cleared by e-mail Date: 9/26/2012 Carey Gordon Tajikistan Acting Country Office Director:

cleared by e-mail Date: 9/27/2012

Charles Specht Turkmenistan Country Office Director: cleared by e-mail Date: 9/26/2012 Benjamin Chapman

Uzbekistan Acting Country Office Director:

cleared by e-mail Date: 9/26/2012 Alison Kosnett

Regional Environmental Advisor for Asia & OAPA:

cleared by e-mail Date: 9/24/2012 Andrei Barannik HEO Director:

Date: ________

Leslie Perry USAID/CAR Mission

Environmental Officer:

Date: ________

Nina Kavetskaya

COR: Quality Health Care Project: cleared by e-mail Date: 9/25/2012 Kairat Davletov

AOR: Dialogue on HIV and TB Project: cleared by e-mail Date: 9/27/2012 Khorlan Izmailova

AOR: MCH APS, WHO Polio:

cleared by e-mail Date: 9/25/2012 Sholpan Makhmudova AOR: WHO Tuberculosis PIO:

cleared by e-mail Date: 9/27/2012 Christina Lau

INITIAL ENVIRONMENTAL EXAMINATION

USAID/CAR/Health

Table of Contents

SECTION 1:

BACKGROUND AND PORTFOLIO DESCRIPTION

SECTION 2:

COUNTRY AND ENVIRONMENTAL INFORMATION (BASELINE INFORMATION)

SECTION 3:

EVALUATION OF PROGRAM ISSUES WITH RESPECT TO ENVIRONMENTAL IMPACT POTENTIAL

Table 1. Environmental Screening of Health Activities

SECTION 4:

RECOMMENDED MITIGATION MEASURES (INCLUDING MONITORING AND EVALUATION)

Table 2. Illustrative Environmental Effects and Mitigation Measures

SECTION 5:

SUMMARY OF FINDINGS

Annexes:

ANNEX 1.

ENVIRONMENTAL REVIEW AND ASSESSMENT CHECKLIST

ANNEX 2.

LEOPOLD MATRIX

ANNEX 3.

STANDARD CONDITIONS FOR SMALL-SCALE ACTIVITIES

ANNEX 4.

ENVIRONMENTAL MITIGATION AND MONITORING PLAN (TEMPLATE)

ANNEX 5.

STANDARD CONDITIONS FOR MEDICAL WASTE DISPOSAL

ANNEX 6.

SAFE MANAGEMENT OF WASTES FROM HEALTH-CARE ACTIVITIES

ANNEX 7.

NEGATIVE ENVIRONMENTAL IMPACTS OF PUBLIC HEALTH COMMODITIES PROCUREMENT; AND GENERATION, STORAGE AND DISPOSAL OF HAZARDOUS AND HIGHLY HAZARDOUS MEDICAL WASTE

Program/Project Data:

Program Objective:

Investing In People

Program Area:

Health (3.1)

Program Elements:

3.1.1 HIV/AIDS

3.1.2 Tuberculosis

3.1.5 Other Public Health Threats

3.1.6 Maternal and Child Health

3.1.7 Family Planning/Reproductive Health

Country/Region:

Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan.

Funding Period:

FY2012 – FY2016

Life of Activity Funding:

estimated $94 million

1. BACKGROUND AND ACTIVITY DESCRIPTION

Overview of USAID/CAR/HEO Health Activities

Upon the breakup of the Soviet Union, Central Asian countries inherited inefficient health systems that they were not able to financially support, arguably with the exception of Kazakhstan. These health finance, service delivery, public health and medical education systems were not able to effectively address the range of problems leading to falling life expectancy in the region. Reforms over the past 20 years have improved Central Asian countries’ ability to address pressing health needs, but much work remains to be done. Specifically, most Central Asian countries are experiencing increasing burdens of HIV/AIDS and multi-drug resistant TB—especially among most-at-risk-populations (MARPS); higher than expected rates of abortion; and lingering high infant and maternal mortality in some areas. A high proportion of physicians has not been well prepared to provide high quality evidence-based services that effectively treat the most common and urgent conditions their people are facing. As mechanisms like the Global Fund to Fight AIDS, TB, and Malaria (GFATM) bring money into Central Asian countries to combat these urgent epidemics, it is vital to work on improving the systems that receive and use these funds so that investments will achieve infectious disease control and reduced mortality.

A healthier population is crucial to Central Asia’s social and economic development and an effective and equitable health care system would be a stabilizing force in a poor and unstable region. Health care is still viewed in the region as a public good that should be universally available. International donor assistance and national government efforts have shown that improvements in general population access and health system efficiency are possible in the region. However, continued fiscal and social pressures in all countries make access to services difficult for vulnerable groups, especially MARPS. Gains achieved for the general population must now be solidified and focus must shift to the most vulnerable populations.

USAID is providing technical assistance and training to the governments of Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan to make fundamental systemic changes to the way vulnerable populations access vital disease care and treatment services, with the goal of creating a more equitable, cost-effective, and efficient health care system that improves vulnerable populations’ access to quality healthcare services. This support includes: conducting outreach to vulnerable populations; strengthening governmental and non-governmental institutions and organizations to plan, implement and evaluate disease prevention and control activities; restructuring financial and health budget systems in pilot oblasts; upgrading the skills of specialists and family doctors; and promotion of more effective and efficient delivery of health services and infectious disease control activities addressing tuberculosis, viral hepatitis, and other diseases. In support of these capacity-building activities, USAID/CAR/HEO is providing limited support for the preparation or rehabilitation of existing facilities to house services when safe or hygienic conditions do not already exist.

The USAID Central Asia Mission proposes to implement these activities to achieve the objective stated in the Mission’s Health Results Framework: to increase vulnerable populations’ access to and utilization of healthcare services, especially for HIV and TB. To achieve this objective, the Health portfolio will focus on four Program Elements (Other Public Health Threats will not receive new funding but ongoing activities will continue until their planned completion), two of them representing the largest share of project activity and resources. Figures are derived from the fiscal year 2012 budget and planned 2013 budget, extrapolated thereafter to 2016:

Major Elements and proportion of funding:

3.1.1 HIV/AIDS (23.9%)

3.1.2 Tuberculosis (60.2%)

Minor Elements and proportion of funding:

3.1.5 Other Public Health Threats (only FY 2011 funds, no future activities in this area)

3.1.6 Maternal and Child Health (11.1%)

3.1.7 Family Planning/Reproductive Health (4.8%)

The following table of current and planned projects, and lists of illustrative activities, are to be implemented during FY2012 - FY2016, under the USAID/CAR Investing in People, Program Area 3.1, Health. Table 1 provides project descriptions proposed with health funding, and the following illustrative list details activities supporting the achievement of the health portfolio objective by program element.

Illustrative activities by program element are included in IEE Section 3.

2. COUNTRY AND ENVIRONMENTAL INFORMATION (BASELINE INFORMATION)

The five Central Asian Republics together have a combined population of 55 million, a land mass greater than Western Europe and a significant share of the world’s oil and gas reserves. Surrounded by Russia, China, Iran and Afghanistan, they are adjacent to and affected by some of the contemporary world’s most pressing ideological, political and economic struggles. These landlocked nations have a history of flux and conquest, with historically limited access to world markets and ideas. The region’s circumstances and prospects still, long after the breakup of the USSR, appear fluid and uncertain. Other than in the hydrocarbon fuels industry in Kazakhstan, the countries of Central Asia suffer from limited investment and isolation from major world markets. Despite potentially vast energy assets and other resources, Central Asian countries are currently classified as low- or low-middle-income and there is considerable poverty and income inequality.

The situation of the health sector in Central Asia has fluctuated dramatically since the fall of the Soviet Union. Health indicators generally worsened for several years after 1991, and then slowly began to improve as countries recovered economically and socially. While many health indicators have returned to levels similar to the end of the Soviet Union, HIV continues to increase—a phenomenon seen today only in this region. Tuberculosis and MDR-TB are also serious issues that Central Asian nations have struggled to address effectively. Primary health care and referrals to specialists are available to the general population, however stigma and discrimination around these diseases and related sensitive behaviors have resulted in limited access to MARPs.

Although each Central Asian country shares a common political and administrative history, they have taken different paths since independence and possess varying social and economic resources to address their health needs. Kazakhstan and Turkmenistan have capitalized on their natural resources, but Kazakhstan has worked towards reforming its health system with international donors while Turkmenistan has chosen to limit outside intervention. Uzbekistan has also largely limited the amount of externally-funded health-related research and implementation, although it has adopted most internationally-recognized reporting guidelines on HIV and TB. Tajikistan and Kyrgyzstan lack the financial resources of their Central Asian neighbors, and receive most of their health budgets from the international community. Health indicators in both countries are the most alarming in the region, and elements of the health system suffered during the lean post-Soviet years, particularly in Tajikistan during the civil war. Low physician salaries, the nascent stage of evidence-based medicine, varying political will for reform, and social stigma around MARPs, HIV and TB in all countries are challenges to further progress.

Environmentally, Central Asia is diverse, with desert, woodlands, steppe, temperate forests, lakes, rivers, and the Caspian Sea in the West. There are about 7000 species of flowering plants and 900 vertebrate species of fauna. There is pressure on water resources in the region, and two of the largest rivers, the Amu Darya and Syr Darya no longer complete their route to the Aral Sea, which has shrunk considerably over the past 50 years. Throughout the region there are established national parks and reserves, although USAID/CAR’s health programming does not occur in any of these protected areas.

Salient regional environmental factors that should be accounted for during health project design, and during implementation as potential effects are: high levels of agro-industrial pollution and liquid and solid wastes in the imminent environment; radioactive pollution and uranium tailings (related to water sources which might otherwise be used for drinking water projects); national and trans-boundary water pollution and concentrations of chemicals and salts in the soil and groundwater; high air pollution; poor sanitation and hygiene; absence of reliable drinking water sources; climate change requiring the introduction of adaptation measures; the rising burden of neglected tropical diseases (NTDs); and inefficient use of irrigation water. These represent the most prominent risks for and as a result of health activities, however all potential adverse environmental factors and effects should be considered during project design and implementation.

3. EVALUATION OF PROGRAM ISSUES WITH RESPECT TO ENVIRONMENTAL IMPACT POTENTIAL

As described in IEE Section 1, all of the specific activities in HIV/AIDS, TB, Other Public Health Threats, Maternal and Child Health, Family Planning/Reproductive Health which involve technical assistance, training, analysis, policy advice and information sharing, studies, academic workshops and meetings, document and information transfers are not expected to pose any environmental risks and qualify for a Categorical Exclusion.

However, in the course of implementation of these activities, implementing partners should take advantage of opportunities to incorporate and improve means of addressing environmental health issues (like hazardous and infectious waste management) into health service delivery systems.

Some projects will purchase office equipment, electric and electronic equipment, and commodities (Section II of Facesheet Table 2) for which no significant adverse effect is anticipated, and therefore Mitigation and Monitoring Plan is not required provided that normal good practices, engineering methods and standard instructions are followed in their procurement, storage, transportation, installation and use. However, these activities qualify for Negative Determination with conditions (NDC), because: 1) the implementer is required to ensure that equipment, commodities, and materials are procured from certified retailers; 2) environmental safety and quality certificates conforming with national and/or international standards are available; 3) equipment and materials are used in an environmentally sound and safe manner, properly disposed of when applicable at the end of their useful life in a manner consistent with best management practices according to USG, European Union or equivalent standards. Electronic devices, including audio-visual components (televisions, VCRs, stereo equipment), mobile phones and other hand-held devices, and computer components, contain valuable elements and substances, are suitable for reclamation, including lead, copper, and gold, if treated properly; however if not treated properly they are a major source of toxins and carcinogens. They also contain a plethora of toxic substances, such as dioxins, PCBs, cadmium, chromium, radioactive isotopes, and mercury. Additionally, the processing required to reclaim the precious substances (including incineration and acid treatments) release, generate and synthesize further toxic by-products.

Activities listed in Section III of Facesheet Table 2 that include procurement, storage, management and disposal of public health commodities, including pharmaceutical drugs, laboratory supplies and reagents; generation, storage, and disposal of hazardous or highly hazardous medical waste, e.g. condoms, sputum samples, sharps distributed by USAID-supported outreach workers and NGOs; other waste such as laboratory reagents and supplies; and small-scale construction activities may cause multiple negative environmental and environmental health effects and therefore qualify for a NDC and require screening, monitoring, evaluation, and reporting to USAID. These effects are discussed in IEE Table 1 and Annexes 5-7.

Below is environmental screening of all proposed Health activities.

Table 1. Environmental Screening Notes:

1) Subcontracts and grants may qualify for NDC activities if they contain NDC activities; and

2) All trainings involving medical kits, chemical reagents, or bio-hazardous materials that may require implementation of safety measures and proper waste disposal, qualify for NDC and require reporting to USAID.

Program Element 3.1: HIV/AIDS

Program Element 3.2: Tuberculosis

Program Element 3.5: Other Public Health Threats (until depletion of pre-FY2012 funds)

Program Element 3.6: Maternal and Child Health

Program Element 3.7: Family Planning/Reproductive Health

4. RECOMMENDED MITIGATION MEASURES (INCLUDING MONITORING AND EVALUATION)

Table 2: Illustrative Environmental Effects and Mitigation Measures

Illustrative Mitigation Measures & Related Links

Education, Technical Assistance or Training

Analysis, Studies, Academic or Research Workshops and Meetings

Document and Information Transfers

Studies, Projects or programs intended to develop the capability of recipient countries and organizations to engage in health planning No environmental impacts are expected from these activities

While the above activities are considered to have no impact on the environment, environmental health and quality considerations should be incorporated into all relevant steps along the healthcare continuum, as part of quality assurance and infection prevention approaches. Implementing partners have an opportunity to include health care waste management messages, and to provide for appropriate disposal facilities in home based care and community based situations. Positive messages about personal and household hygiene, sanitation, and proper disposal of potentially harmful materials should also be delivered, as appropriate, along with the standard health care messages. It is USAID policy to assist developing countries in strengthening their capabilities to evaluate potential environmental effects. Any facility-based surveys should include appropriate environmental questions, for example: a) How does the clinic/hospital safely dispose of its sharps and medical waste? b) Are facility staff trained and equipped to identify and treat chemical intoxications? (for areas where the government is supporting use of agricultural or other chemicals); c) Does the facility have access to an improved drinking water source and improved sanitation facilities? d) Does the facility staff do outreach on environmental health issues including water, sanitation and hygiene, chemicals, and solid waste disposal?

If the topic of these activities is one that inherently affects the environment, such as training in HIV/AIDS and/or TB testing that involves use and disposal of medical waste, the training should include information on safe disposal…