Attachment_7_Initial_Environment_Examination.pdf

INITIAL ENVIRONMENTAL EXAMINATION

OR

CATEGORICAL EXCLUSION

PROGRAM/ACTIVITY DATA:

Program/Activity Number: Integrated Health (IH) Portfolio (611-007)

Country/Region: Zambia/Southern Africa

Development Objective DO3: IR 3.2: Health Status Improved

Program Area 3.1: Health 3.3: Social and Economic Services and Protection for Vulnerable Populations

Program Elements 3.1.1: HIV/AIDS 3.1.2: Tuberculosis 3.1.3: Malaria 3.1.6: Maternal and Child Health 3.1.7: Family Planning and Reproductive Health 3.1.9: Nutrition 3.3.1: Policies, Regulations and Systems

Funding Begin: FY 2012 Funding End: FY 2017 Funding

LOP Amount: $1.7 Billion

IEE Prepared By: Melinda Roberts, Mlotha Damaseke, USAID Lusaka

Current Date: May 30, 2013

Expiration Date: September 30, 2017

IEE Amendment1 (Y/N): __No__ If "yes", Filename & date of original IEE: _N/A____

Other Pertinent Environmental Compliance Documents:

Indoor Residual Spraying for Malaria Control in Zambia to include 53 districts...

Details for file #GH-IEE-12-003 (PDF). ETD Signature Date 2011-11-08

Indoor Residual Spraying (IRS) Indefinite Quantity Contract (IQC) Details for file #Zambia_IRS_SEA_Amend_070810 (DOC) (PDF). ETD Signature Date 2010-06-01

1 Previous IEEs amended and extended several times, now superseded (2007) and the two SOs have been integrated:

• Special Objective (SO 9): Reduced HIV/AIDS Impact Through Multi-Sectoral Response

34Zambia2_SO9_HIVAIDS.iee (PDF)

• SO7: Improved Health Status of Zambians -- file #GH-2007-014 (PDF)

• SO7: Improved Health Status of Zambians - Zambia_FY07_SO7_Health_Amend_0607.iee (DOC) (PDF javascript:%20f_open_document(37978);

http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/37978.pdf javascript:%20f_open_document(25544);

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http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/636.pdf javascript:%20f_open_document(490);

http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/490.pdf javascript:%20f_open_document(724);

http://gemini.info.usaid.gov/egat/envcomp/repository/doc/724.doc http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/724.pdf

ENVIRONMENTAL ACTION RECOMMENDED: (Place X where applicable) Categorical Exclusion: X Negative Determination: X

Deferral:____________

ADDITIONAL ELEMENTS: (Place X where applicable)

CONDITIONS: X EMMP: __X__ PVO/NGO: X

SUMMARY OF FINDINGS

The purpose of this Initial Environmental Examination (IEE) is to provide the necessary environmental review and documentation, per 22 CFR Part 216, for proposed activities of the USAID/Zambia Health and Multisectoral HIV/AIDS Teams implemented in an integrated health portfolio. The IEE evaluates proposed activities under the third Development Objective (DO) of USAID/Zambia’s approved Country Development Cooperation Strategy (CDCS) FY 2011-2015. Two intermediate results operationalize the DO, one of which (IR 3.2) relates to health, Health Status Improved, which is further broken down into three sub-intermediate results: 1) Health Service Delivery Improved; 2) Health Systems and Accountability Strengthened; and 3) Community Health Practices Improved.

This IEE addresses proposed activities of the USAID/Zambia Integrated Health Portfolio. Integrated health objectives and goals all align closely with the Government of the Republic of Zambia’s National Health Strategic Plan (2011-2015). Activities promotes access, as close to the community as possible, to high-quality, cost-effective health services. The key principle of USAID/Zambia’s Integrated Health portfolio includes a primary health care approach, equity of access, affordability, cost-effectiveness, accountability, partnerships, decentralization and leadership, and a clean, caring, and competent health care environment.

DO 3 addresses the numerous health challenges in Zambia, in part, through the integration of activities attributed to numerous USG health initiatives and endeavors, including the Global Health Initiative (GHI), the Presidential Malaria Initiative (PMI), Feed the Future (FtF), The President’s Emergency Plan for Aids Relief (PEPFAR), and Saving Mothers, Giving Life (SMGL). Given the various and interlinked health challenges in Zambia, the Project assumes that the combination of these activities will result in sustained improvements in the health status of the Zambian population.

This DO will support activities in support of national health and development priorities across several health elements (family planning/reproductive health, HIV/AIDS, maternal and child health, malaria, nutrition, and tuberculosis) and three intermediate results: improved health service delivery, strengthened health systems, and accountability, and improved community-level health practices.

IR 3.2.1 Improving Health Service Delivery: Geographic access to healthcare varies greatly between urban and rural areas: 99% of urban households reside within five kilometers of a health facility, compared to only 50% of rural households. Assistance activities will work to improve access to and utilization of health services and the quality of care provided to Zambians, and gradually strengthen local capacity to deliver those services directly. Activities will cover relevant health elements, and where appropriate will integrate services.

Activities that fall under service delivery will include supervision of the direct delivery of clinical and community health services, which have the potential to impact the environment.

Those activities which are not expected to have a direct effect on the environment include:

• Mentoring, Counseling, and Supervision

• Sexually transmitted infection counseling to vulnerable populations in high risk settings.

• National policy and regulatory guideline development that do not impact the capacity of the health workforce, facilities, and management systems to deal with medical waste and biosafety issues

• Advocacy and counseling for HIV/AIDS treatment and care services

• Psychosocial support, prevention and legal services to victims of Gender Based Violence

• Vitamin A supplementation, growth monitoring, and nutritional education

• Technical support/advice to National Malaria Control program, National TB Control

Program, or other management directorates within the Ministry of Health, Ministry of Community Development, Mother and Child Health, or other Multisectoral Ministries dealing with health issues.

• Community mobilization supporting the Expanded Program on Immunization, the Integrated Management of Childhood Illnesses, or Integrated Community Case Management model to prevent childhood deaths

• Expansion of Safe Motherhood Action Group (community mobilization) activities

• Increased counseling around contraceptive method choice/method mix

• Integration of Family Planning counseling with Safe Motherhood and HIV/AIDS service delivery programs

Categorical Exclusions from further environmental examination are recommended for the following classes of activities under 3.2.1, except to the extent that the activities directly affect the environment (such as construction of facilities). Specifically, this is for activities covered by the following citations in Reg. 216, by subparagraph of 22 CFR 216.2(c)(2):

(i) Activities involving education, training, technical assistance or training programs;

(ii) Activities involving controlled experimentation exclusively for the purpose of research and field evaluation and carefully monitored;

(iii) Activities involving analyses, studies, academic or research workshops and meetings;

(v) Activities involving document and information transfers;

(viii) Programs involving nutrition, health care, or family planning services except to the extent designed to include activities directly affecting the environment (such as construction of facilities, water supply systems, waste water treatment, etc.); and

(xiv) Studies, projects or programs intended to develop the capability of recipient countries and organizations to engage in development planning.

However, there are qualifiers associated with these categorical exclusions, e.g., if any topic associated with these activities is one that inherently affects the environment, such as training in HIV/AIDS testing that involves use and disposal of medical waste, or training related to malaria prevention then such training will include information on how to minimize and/or mitigate these impacts. Examples include, instruction on safe disposal of sharps and biological samples generated from HIV/AIDS testing or training in proper household behaviors to minimize exposure during indoor residual spraying campaigns and proper use of insecticide-treated materials like bed nets. Likewise, demand creation efforts for VCT, etc., have downstream implications on health care waste management capacity.

Negative Determinations with Conditions are recommended, per 22 CFR 216.3(a)(2)(iii), for the following illustrative examples of activities with subsequent impact on the environment:

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

• Treatment of malaria, HIV/AIDS, TB, and other illnesses or health complications during delivery: Activities such as direct clinical or treatment services have the potential for generation and disposal of medical waste. It is required that best practice approaches be adopted to ensure that adequate application of medical waste management and disposal procedures are exercised.

The overall issue of disposal extends to the use of sharps for the treatment of severe malaria and diagnosis, use of rapid diagnostic tests, and blood for diagnosis and other bio-hazardous waste, including contaminated materials, and toxic or hazardous materials used in laboratories and in treatment protocols, as well as storage and disposal of treatment therapies and other pharmaceutical medicines.

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

To mitigate any potential environmental impact of these activities, beyond regular monitoring visits to activity sites, the Health Team, in particular, COR and AORs for individual activities will work with implementing partners to assure, to the extent possible, that relevant medical facilities and operations have adequate procedures and capacities in place to properly handle, label, treat, store transport and properly dispose of blood, sharps, and other medical waste as articulated in Chapter 8 of the Environmental Guidelines for Small Scale Activities in Africa’s ‘Minimum Elements of a Complete Waste Management Program. Where adequate procedures do not exist, AORs and CORs will work with implementing partners to ensure such procedures and capacities are developed and instituted.

Important to note, however, is the ability of the Team to assure such capacity is understood to be limited by its level of control over the management of facilities and operations that USAID/Zambia is supporting.

In addition, the lack of adequate resources, by both USAID and GRZ, may limit the ability to implement and sustain a full medical waste disposal program. But, as described in Annex 1, a Minimal Checklist could be implemented at low cost. Collectively, the GRZ, donors, NGO/PVO community, and private sector could organize a plan for coordinated and incremental improvements

IR 3.2.2 Strengthening Health Systems and Accountability: USAID/Zambia activities to improve health systems and accountability are based on the National Health Strategic Plan and Partnerhsip Framework Implementation Plan (PFIP) building blocks and will include improving human resource capacity and management, commodity and drug logistics, management and information systems, health governance and accountability, health financing, and capacity to conduct research and develop new interventions. This includes activities to strengthen the systems which underpin Zambia’s response to HIV and AIDS, malaria, maternal health, child health, nutrition, and TB.

As implementation of the majority of these activities entail education, trainings, workshops, analyses, studies, and health care planning services, they are not expected to result in any direct effect on the environment, and as such, are recommended for Categorical Exclusion per 22CFR216.2(c)(2)(i) [education, technical assistance, training]; (iii) [analyses, studies, workshops and meetings]; (v) [document and information transfer]; and (viii) [nutrition, health care or population and family planning services].

A limited number of activities may have a direct effect on the environment. These activities include after-use management of condoms, family planning commodities and point-of-use water purification solutions, and the promotion of insecticide-treated mosquito nets. These are recommended for Negative Determination with Conditions, per 22 CFR 216.3(a)(2)(iii), with conditions to fulfill spelled out in Table 1, Section 4.1

Sub IR 3.2.3 Community Health Practices Improved:

Activities to improve community health practices are designed on the assumption that healthy living and disease prevention is more cost effective than treatment and an important factor and part of any healthcare system. In particular, USAID will support a multi-pronged multimedia advocacy campaign that will coordinate with community organizations to reach targeted vulnerable populations, increasing their knowledge and acceptance of preventive behaviors and healthy practices. Increasing preventive behaviors should reduce the burden on the health care system. Activities in support of this result will focus on orphans and vulnerable children to ensure their inclusion within the health care system and essential nutrition actions designed to improve nutrition at key stages in childhood development.

Assistance activities will work with community organizations to reach citizens and increase their knowledge of preventive behaviors and healthy practices. Healthy living and disease prevention is more cost effective than treatment. Increasing Zambian’s preventive behaviors will reduce the burden on the health care system.

Activities in support of this result will focus on orphans and vulnerable children to ensure their inclusion within the health care system, and essential nutrition actions designed to improve nutrition at key stages in childhood development.

Proposed activities will improve human resource capacity and management, drug logistics, monitoring systems, and increase capacity to conduct research and develop new interventions. As implementation of these activities entail education, trainings, workshops, analyses, studies, and health care planning services, they are not expected to result in any direct effect on the environment, and as such, are recommended for Categorical Exclusion per 22CFR216.2(c)(2)(i) [education, technical assistance, training]; (iii) [analyses, studies, workshops and meetings]; (v) [document and information transfer]; and (viii) [nutrition, health care or population and family planning services].

MONITORING AND GENERAL COMPLIANCE CONDITIONS

General Project Implementation and Monitoring Requirements In addition to the specific conditions enumerated in Section 4 of this IEE, the negative determinations recommended are contingent on full implementation of the following general monitoring and implementation requirements:

1. Implementing Partner (IP) Briefings on Environmental Compliance Responsibilities. The Integrated Health team shall provide each IP, with a copy of this IEE. Each IP shall be briefed on their environmental compliance responsibilities by their cognizant C/AOR and/or MEO. During this briefing, the IEE conditions applicable to the IP’s activities will be identified.

2. Development of EMMP. Each IP whose activities are subject to one or more conditions set out in Section 3 of this IEE shall develop and provide for C/AOR and/or MEO review and approval an EMMP documenting how their project will implement and verify all IEE conditions that apply to their activities.

These EMMPs shall identify how the IP shall assure that IEE conditions that apply to activities supported under subcontracts and sub-grant are implemented. (In the case of large sub-grants or subcontracts, the IP may elect to require the sub-grantee/subcontractor to develop their own

EMMP.)

(Note: refer to the AFR EMMP Factsheet, available at http://www.usaidgems.org/mitMonRep.htm.)

3. Integration and implementation of EMMP. Each IP shall integrate their EMMP into their project work plan and budgets, implement the EMMP, and report on its implementation as an element of regular project performance reporting.

IPs shall assure that sub-contractors and sub-grantees integrate implementation of IEE conditions, where applicable, into their own project work plans and budgets and report on their implementation as an element of sub-contract or grant performance reporting.

4. Integration of compliance responsibilities in prime and sub-contracts and grant agreements.

a. The Integrated Health team shall assure that contracts or agreements for implementation of the project, and/or significant modification to current contracts/agreements shall reference and require compliance with the conditions set out in this IEE, as required by ADS 204.3.4.a.6 and ADS 303.3.6.3.e.

b. IPs shall assure that sub-contracts and sub-grant agreements reference and require compliance with relevant elements of these conditions.

6. Assurance of sub-grantee and sub-contractor capacity and compliance. IPs shall assure that sub-grantees and subcontractors have the capability to implement the relevant requirements of this IEE. The IP shall, as and if appropriate, provide training to sub-grantees and subcontractors in their environmental compliance responsibilities and in environmentally sound design and management of their activities.

7. Integrated Health Team monitoring responsibility. As required by ADS 204.5.4, the cognizant C/AOR, with oversight from the IH Team Leader will actively monitor and evaluate whether the conditions of this IEE are being implemented effectively and whether there are new or unforeseen consequences arising during implementation that were not identified and reviewed in this IEE. If new or unforeseen consequences arise during implementation, the C/AOR, with agreement from the IH Team Leader and AO/CO, will suspend the activity and initiate appropriate, further review in accordance with 22 CFR 216. USAID Monitoring shall include regular site visits. The process of environmental monitoring and evaluation will be integrated into the IH team’s Performance Monitoring and Evaluation Plan.

8. New or modified activities. As part of its initial Work Plan, and all Annual Work Plans thereafter, IPs, in collaboration with their C/AOR, shall review all planned and on-going activities to determine if they are within the scope of this IEE.

If any IP activities are planned that would be outside the scope of this IEE, an amendment to this IEE addressing these activities shall be prepared for USAID review and approval. No such new activities shall be undertaken prior to formal approval of this amendment.

Any ongoing activities found to be outside the scope of the approved Regulation 216 environmental documentation shall be halted until an amendment to the documentation is submitted and written approval is received from USAID. This includes activities that were previously within the scope of the IEE, but were substantively modified in such a way that they move outside the scope.

9. Compliance with Host Country Requirements. Nothing in this IEE substitutes for or supersedes IP, sub-grantee and subcontractor responsibility for compliance with all applicable http://www.usaidgems.org/mitMonRep.htm host country laws and regulations. The IP, sub-grantees and subcontractor must comply with host country environmental regulations unless otherwise directed in writing by USAID. However, in case of conflict between host country and USAID regulations, the latter shall govern.

10. Government-to-government (G2G) assistance. In keeping with USAID Forward, investment in country-led plans is an important value, which may include consideration of sector program assistance (SPA) or other government-to-government assistance. In this event, USAID/Zambia will need to obtain Authorization for Use of Partner Country Systems (AUPCS)—a relatively new requirement for G2G assistance specified in ADS 220: Use of Reliable Partner Country Systems for Direct Management and Implementation of Assistance. This will include certification of the effectiveness of Zambia’s environmental assessment procedures, policy and legislative framework, institutional capacity and culture to actually apply and implement the procedures.

This certification likely will require that a capacity assessment be implemented to assure that host government systems are capable of ensuring sound environmental compliance and where gaps are identified appropriate capacity building measures will be recommended as conditionalities to the final approval of an AUPCS This should also be harmonized with the expectations of other sector donors (World Bank, EU, etc.), in line with the Paris Declaration of Aid Effectiveness.

These procedures are intended to ensure that the IEE findings and conditions are implemented as a matter of routine project implementation. As described below, these procedures are themselves general conditions of approval for the IEE; their implementation is therefore mandatory.

USAID Team Responsibilities and Requirements:

The USAID/Zambia Integrated Health team A/CORs, with oversight from the Team Leaders, in consultation with the Mission Environmental Officer (MEO), Deputy MEO, AO/CO, the Regional Environmental Advisor (REA), and the Bureau Environmental Officer (BEO), as appropriate, will actively monitor and evaluate environmental consequences arising during implementation. He/she will modify or terminate activities if they are deemed harmful to the environment. In the event that unforeseen environmental impacts are determined or that mitigation and control measures are insufficient, the AOR/COR will consult promptly with the Mission Environmental Officer. USAID’s primary role is to monitor implementing partners’ compliance with this IEE.

a) The AOR/COR will ensure that new project activities are covered under an Environmental Screening Form (ESF) before implementation occurs; partners will use the Africa Bureau Environmental Review Form (ERF), www.encapafrica.org/documents/AFR-EnvReviewForm- 20Dec2010.doc.

b) The AOR/COR will provide to the prime contractor the IEE conditions and the mitigation measures for the activities to which they apply;

c) Selection of sub-contractors and/or grantees should include consideration of their ability to perform the mandatory environmental compliance requirements as set forth herein. The Office of Acquisition and Assistance (OAA) will include required environmental compliance and reporting language into each sub-agreement to the prime partner. The Team Leader and the AOR/COR will subsequently ensure that appropriate budget, resources, staff, equipment, and reporting procedures are contained in proposals to conduct environmental compliance, and that implementing partners undertake mitigation and monitoring measures as a routine course of program implementation;

d) The AOR/COR will undertake regular and timely field visits and consultations with implementing partner to jointly assess the environmental impacts of ongoing activities, and associated mitigation and monitoring conditions; and, http://www.encapafrica.org/documents/AFR-EnvReviewForm-20Dec2010.doc http://www.encapafrica.org/documents/AFR-EnvReviewForm-20Dec2010.doc

e) USAID may facilitate and/or subsidize the delivery of activity-specific environmental training to the contractors and sub-contractors, as appropriate.

Implementing Partner Responsibilities and Requirements:

The Implementing Partner (IP) is responsible for adherence to this IEE. The IP will:

a) Develop an Environmental Mitigation & Monitoring Plan (EMMP) describing how the project will implement the conditions in the IEE. This shall include training of contractor staff and sub-partners, when appropriate;

b) Undertake regular field visits to monitor and evaluate program activities to assess their environmental impact, and the effectiveness of USAID-proposed mitigations measures and Best Management Practices (BMPs);

c) Include in its quarterly reports a brief update on mitigation and monitoring measures being implemented, and results/findings of environmental monitoring visits;

d) Ensure that any grants or fund transfers to other organizations (sub-partners) incorporate provisions stipulating that an annual environmental monitoring report will be completed; and that proposed activities are within the scope of the environmental determinations and recommendations of this IEE. This shall include assurance that all mitigating measures required for those activities are followed; and

e) Complete an annual environmental mitigation and monitoring report of activities undertaken during the fiscal year (Oct 1 – Sept 30) unless specified otherwise. This report will be submitted to the AOR/COR together with the Annual Report. This reporting requirement shall be incorporated into the project’s performance monitoring plans and annual work plans.

The environmental monitoring information shall be compiled by the AOR/COR and submitted to the Environmental Team Leader and the REA for incorporation into the annual Performance Plan and Report.

As required by ADS 204.3.4, CORs and AORs will actively monitor ongoing activities for compliance with approved IEE recommendations, and modify or end activities that are not in compliance. If additional activities, not included in this document, are added to the project, an amended environmental examination will be submitted.

CLEARANCE:

Acting Deputy Mission Director, USAID/Zambia: __/Cleared/________ Date: _7/5/2013______ Joseph T. McGee

CONCURRANCE

Bureau Environmental Officer: _____________________________ Date: _______ Brian Hirsch

ADDITIONAL CLEARANCES: (Type Name Under Signature Line)

Health Team Leader: _______/cleared/___________________ Date: __6/4/2013_____ Sangita Patel

Mission Environmental Officer: _________/cleared/________________ Date: __6/4/2013_____ Mlotha Damaseke

Supervisory Program Officer: ________/cleared/________________ Date: 6/13/2013______

Debra Mosel

Deputy Mission Director: ________/cleared/________________ Date: ___6/13/2013___ Ryan Washburn

Acting Regional Environmental Advisor: /cleared/ Date: 6/27/2013 Walter Knausenberger

File No: Zambia_Integrated_Health_Portfolio_IEE_2013_6-27-13.doc

INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ACTIVITY DATA:

Program/Activity Number: 611-007 Country/Region: Zambia Program Name: DO 3: IR 3.2: Health Status Improved

1.0 BACKGROUND AND PROGRAM DESCRIPTION

1.1 Introduction

Zambia is known for its peaceful people, incredible natural beauty, fertile soil, and vast mineral wealth.

With an increase in copper prices and sound macroeconomic policies, Zambia’s economy started rising in the late 1990s and has averaged five to six percent Gross Domestic Product (GDP) growth over the past decade. Impressive macro-level performance, however, belies the reality facing most Zambians. Zambia’s new Sixth National Development Plan (SNDP) notes, “the economic growth experienced during the last decade has not translated into significant reductions in poverty and improved general living conditions of the majority of Zambians.” This is particularly true for rural Zambians where 80% of the population lives in poverty, of which 63% live below $1.25 per day. Health and education constraints limit the ability of many Zambians to fully participate in economic opportunity. Of Zambians between the ages of 15-49, 14.3% are HIV positive while nearly half of Zambia’s children under five are stunted. Barely 20% of Zambia’s learners finish secondary school, with girls particularly disadvantaged.

1.2 Purpose and Scope of this Initial Environmental Examination (IEE)

The purpose of this IEE is to provide the necessary environmental documentation, pursuant to 22 CFR 216 and ADS 204, for activities aimed towards Empowering Zambia for Improved Health. This document provides the necessary, pre-implementation environmental compliance requirements are in place, so as to ensure that implementation of project activities abide by USAID Environmental Policies and Procedures.

This IEE does not cover any use of pesticides, as stated in the Africa Bureau, Environmental Guidelines for Small-Scale Activities in Africa, concerning the procurement, handling and use of pesticides. The previous health sector IEEs in the past ten years are: SO 9 Health IEE and SO 7 HIV/AIDS IEE (2004, 2007); and amendments for Health and HIV (2010, 2013)2 . The two former SOs, SO7: Improved Health Status of Zambians, and SO7 Reduced HIV/AIDS Impact Through Multi-Sectoral Response have been combined into one Integrated Health Portfolio.

This IEE provides the basis for relevant Threshold Determinations of project activities to ensure they meet environmental compliance regulations as detailed in 22 CFR 216 and ADS 204. COR and AORs of individual activities are responsible for ongoing environmental monitoring of activities to ensure that the environmental impact of activity remains within the boundaries of their approved determinations. As new activities are included, existing ones are extended or modified, or if activities unexpectedly produce environmental impacts beyond approved designations, the IEE will be amended accordingly.

2 2012 IEE extensions, superseded by this IEE:

SO 7: Investing In Health-HIV/AIDS, Zambia_HIV_IEE_Extension_020613 (DOCX) (PDF) SO 9: Investing in People-Health: Zambia_Health_Extension_020613 (DOCX) (PDF) javascript:%20f_open_document(39060);

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1.3 Results Framework for Development Objective 3 (DO3): Human Capital Improved:

Intermediate Result 3.2: Health Status Improved

This DO will support Improved Human Capital associated with health through Intermediate

Result (IR) 3.2: Health Status Improved and its sub-IRs: 3.2.1.improved health service delivery;

3.2.2. strengthened health systems and accountability; and 3.2.3. improved community-level health practices

All programs aimed at Empowering Zambia for Improved Health are premised upon the underlying hypothesis that improved health service delivery, combined with stronger and more accountable institutions, and increased awareness of healthy practices and healthy lifestyles, will result in healthier Zambians. Activities to support this result will fall under one of three component results:

1.3.1 Sub-IR 3.2.1 Health Service Delivery Improved: Geographic access to healthcare varies greatly between urban and rural areas: 99% of urban households reside within five kilometers of a health facility, compared to 50% of rural households. Assistance activities will work with the Ministry of Health to improve the quality of care provided by institutions, as well as their ability reach Zambians. Activities under this intermediate result will focus on increasing access to health services, improving service quality, and improving utilization of clinical services. To improve health service delivery, the Mission will support integrated service delivery using existing platforms to expand access at facilities. While non-governmental and faith-based organizations will assist in some service delivery, USAID/Zambia will emphasize strengthening government capacity to offer services, either through public sector facilities and government supported community level structures, or through contracting for specialized service delivery to capable local institutions directly. Activities will focus on improving access, quality, and utilization of clinical services, will cover all health elements, and where appropriate, will integrate services.

Family Planning/Reproductive Health (FP/RH) Activities

USAID/Zambia supports a number of approaches and multiple channels to maximize access to and quality of FP/RH services, including the public, private, NGO and FBO sectors. USAID supports integration of FP/RH within HIV and AIDS services and in programs for youth and OVC. USAID will strengthen delivery systems and service providers in FP/RH and support the expansion of contraceptive method mix and other key reproductive health products. In addition, USAID will work closely with the GRZ to facilitate the integration of FP/RH with HIV and AIDS, maternal health and child health services where feasible.

1. Implement best practices related to improving family planning and reproductive health service delivery, including:

• Socially market and distribute contraceptives (oral contraceptives, male/female condoms) through the private sector and promote the female condom.

• Identify, train and support community-based distributors of FP information and selected services (condoms, oral contraceptives) and expand community-based distribution of contraceptives to include injectable methods by taking results from pilot efforts to scale.

• Strengthen the skills of facility-based public sector provider to offer entire range of FP methods, with explicit attention to injectable and long-term and permanent contraceptives.

• Explicitly integrate FP/MCH/N services and effective referrals into PEPFAR-funded OVC and care/support basic care packages and activities.

• Support the implementation of the adolescent reproductive health strategy.

• Expand method mix by introducing fertility awareness methods such as standard days method (cycle beads).

• Strengthen facility post-partum FP counseling to include messages on healthy timing and spacing of pregnancy, lactational amenorrhea (LAM) and early post-partum IUD insertion.

• Strengthen service delivery capacity and referral network for long-term and permanent methods for rural and hard-to-reach populations.

Maternal and Newborn Health Activities

USAID/Zambia gives high priority to reducing maternal and neonatal mortality with a focus on:

increasing access to Emergency Obstetric and Neonatal Care (EmONC) during pregnancy, delivery, and the post-delivery period; increasing access to skilled birth attendants who can provide basic and comprehensive emergency obstetric and newborn care; increasing accessibility to these services, especially in rural areas; and addressing the need for social and behavioral change communication around safe motherhood. USAID will provide support to the GRZ through three distinct but complementary strategies: 1). The BEST Action Plan that works at a national level, 2). The Saving Mothers, Giving Life

GRZ-USG interagency endeavor that works in selected districts to accelerate maternal mortality reduction by applying a district strengthening approach and focusing on labor, delivery and the first 24 hours postpartum; and 3). Helping Babies Breathe, a public private partnership to reduce neonatal deaths due to birth asphyxia through neonatal resuscitation. MNH illustrative activities are:

2. Implement best practices for improving maternal health service delivery, including:

• Expand access to Emergency obstetric and neonatal care (EmONC) including active management of the third stage of labor, essential newborn care, and post-abortion care with FP counseling & services on site.

• Assist GRZ to expand EmONC by deploying national level advisors, training national EmONC trainers, enhancing skills of provincial level clinical care specialists as trainers/mentors, and training and mentoring facility level EmONC providers.

• Expand home-based lifesaving skills, e.g. recognition of danger signs, emergency transport from pilot sites through SMAGs.

• Support targeted facility upgrades for EmONC to improve quality of services.

3. As part of the Saving Mothers, Giving Life USG interagency endeavor, GRZ and global partnership, pilot SMGL in select districts of Zambia building on Ministry of Health platforms and scale-up in additional districts upon successful completion of the pilot, including:

• Conduct health facility surveys to identify gaps in human resources, skills, supplies, equipment, drugs and medicine, infrastructure, SI/HMIS, transport, communications, community mobilization, and birth preparedness.

• Address gaps based on findings of the facility survey to ensure access to quality safe delivery and emergency obstetric care in Mansa plus additional districts after 2012.

• Provide technical support in the training and mentoring of health personnel in EmONC in an initial four select districts and expand to additional districts as per scale-up plan.

• Strengthen the mother-child care continuum via integration of critical MNCH services around the delivery and first 24 hours such as HIV testing and PMTCT, skilled attendance at birth, active management of third stage of labor to prevent post-partum hemorrhage, emergency obstetric and neonatal care, essential newborn care, and immediate postpartum family planning.

• Conduct a costing study to document initial investment costs and later costs of providing key signal functions for EmONC, safe delivery, transportation and communication.

• Assist in finding innovative transportation and communication solutions.

• Work with the USG interagency team, GRZ, implementing partners, and the SMGL global partnership to assess the pilot and plan for scaling up successful components of SMGL to additional districts.

4. Implement best practices for essential neonatal health service delivery, including:

• Strengthen essential newborn care and newborn resuscitation at both facility and community levels and support adaptation of local training materials with accepted global standards (Helping Baby Breathe curricula).

• Accelerate guideline/policy harmonization regarding postnatal visits to be consistent with WHO recommendations (within 24 hours and 3 days postpartum).

• Scale-up neonatal resuscitation within EmONC training for facility-based health workers.

• Train community volunteers (tTBAs and CHW) in essential newborn care (including neonatal resuscitation, thermal control, signs of illness in the newborn and danger signs, early initiation of breast feeding).

• Expand community-level sepsis management from pilot research results to small scale implementation through operational approaches sustainable by the current health system, and document continued impact on neonatal mortality.

Child Health Activities

USAID will redirect efforts to immunization program activities and have more modest expectations for other community-based interventions such as case management for the major killers of Zambian children

– malaria, diarrhea, and respiratory infections/pneumonia. USAID will support MOH to assess and improve the effectiveness of the Reach Every District (RED) strategy through capacity building for provincial, district and health center and personnel as well as community volunteers. USAID plans to support implementation of the National Community Health Worker Strategy and IMCI training materials for new IMCI providers.

5. Implement best practices for child health service delivery, including:

• Expand access to integrated case management of childhood illnesses (particularly treatment as indicated for malaria with ACTs, pneumonia with antibiotics, and diarrhea with ORS/Zinc) at both facility and community levels (i.e., f-IMCI, c-IMCI, and iCCM) by training and supervising health workers, CHWs and community volunteers.

• Improve immunization coverage primarily through employing the Reach-Every-District (RED) strategy, particularly in low performing districts.

• Provide technical assistance from province down to facility levels for the biannual Child Health Week (which include routine immunization; Vitamin A supplementation; HIV testing and early infant diagnosis; health education on nutrition, FP and hand washing with soap).

• Provide technical assistance to introduce pneumococcal vaccine.

• Support cold chain strengthening for routine and new vaccines, including a nationwide assessment of the cold chain.

Nutrition

Nutrition activities respond to Feed the Future (FtF), BEST (best practices) and the Global Health Initiative. To the extent possible, activities will be focused in the same geographic areas as the agriculture activities that form the FtF set of interventions. USAID will increasingly coordinate its activities with those of other stakeholders in support of the National Food and Nutrition Strategy (2011-15). The nutrition program is largely managed by the USAID Economic Growth Team with contributions from USAID/Zambia’s Health and HIV Offices and CDC.

6. Implement best practices for nutrition service delivery, including:

• Train and supervise community volunteers (SMAGs, CHWs, etc.) to provide nutrition information, products and services.

• Support national review, policy revision and roll out of new guidelines on HIV and Infant Feeding per the WHO 2009 Rapid Advisory.

• Support an integrated adolescent health program, including adolescent anemia prevention, in line with the adolescent reproductive health strategy.

7. Link with FTF Zambia nutrition activities, including:

• Invest in capacity building and training of health workers to improve the nutrition services and nutritional education.

• Build strong linkages to rural health services and nutrition interventions.

• Participate in the development of a National Nutrition Strategy and convening of a National Nutrition Consultative Forum to discuss the strategy.

• Zambia will be An Early Riser, under the Scaling Up Nutrition (SUN) Initiative promoted by the U.S. and a wide range of other donors.

• Participate in the Nutrition Donor Convener Group, chaired by DFID and UNICEF, under the Health Sector Working Group.

• Improve effectiveness of nutrition services in health facilities and at the community level Significantly increase focus on women, especially pregnant women at nutritional risk (low Body Mass Index (BMI) and those under the age of 20).

• Develop capacity of managers, health care providers and community volunteers in regard to nutrition interventions, particularly ensuring that Essential Nutrition Actions are coordinated and implemented in all health facilities at the district level

• Integrate the “Community Pack for maternal and child feeding” (Behavioral Change Communication (BCC) messages and materials) into Community Health Worker and health care providers training curricula.

• Strengthen the “Promotion” component of Growth Monitoring and Promotion programs.

Coordinate and link Food Security and Nutrition interventions across all sectors at the district level, including the school feeding program.

• Dissemination of Vitamin A maize in the Eastern Province of Zambia Development and dissemination of orange-fleshed sweet potato varieties for Zambia.

8. Implement the Zambia Nutrition Assessment, Counseling and Support for nutrition-related HIV/AIDS interventions, including:

• Implement ZAMNACS in targeted sites. At least 10 % of the sites will be co-located with FTF districts for coordinated and complementary nutrition interventions.

• Begin implementation in the FTF core geographical area of Eastern Province to support the delivery of Nutrition Assessment, Counseling and Support (NACS) services for HIV-positive individuals as well as Orphans and Vulnerable Children (OVC).

• Strengthen referrals/linkages between health facility and community-based nutrition programs.

• Support local food companies to product high energy protein supplements (HEPS).

HIV and AIDS

USAID/Zambia is a key USG agency implementing PEPFAR and provides significant support for improving services for HIV prevention, care and treatment through public, private, faith-based and civil society services. USAID implements PEPFAR activities under the Partnership Framework Implementation Plan 2011-2015 that is aligned with the National HIV/AIDS Strategic Framework.

PEPFAR supported activities to improve HIV and AIDS service delivery, include:

9. Activities to accelerate and intensify prevention in order to reduce the annual rate of new HIV infections:

• Prevent family transmission of HIV including MTCT, e.g. support for early infant diagnosis, expansion of services for HIV discordant couples, forecasting and procurement of ARVs for PMTCT, and integration of HIV prevention and other health programs (see integration). [PFIP]

• Integrate prevention in all aspects of care at all healthcare settings, e.g. develop on-site referrals and off-site referrals, including CSO, private sector and community based for additional health care services.

• Scale-up access to and use of testing and counseling services, e.g. mobile and home-based services, procure test kits, train and deploy lay counselors for HIV, expand services for couples TC and mutual disclosure, expand workplace programs, build linkages to care and treatment for those who test positive.

• Support coordinated combination prevention program that includes continued scale up of biomedical prevention such as voluntary medical male circumcision (VMMC) to achieve the target of 80% of adult men circumcised by 2015.

• Support the revision of the PMTCT guidelines and its roll-out and implementation of Option B+.

• Continue support for gender-based interventions addressing inequalities, GBV, prevention methods targeting women such as the female condom, and post-exposure prophylaxis.

• Continue HIV prevention activities among key populations along transit corridors, borders and in select urban areas.

• Design and implement multisectoral activities targeted at high risk and HIV positive adolescents (including older OVC and those on ART) and youth for prevention of HIV, STIs, and unintended pregnancies.

10. Activities for accelerating universal access to comprehensive and quality treatment, care and support for PLHIV, including services for TB and STIs and opportunistic infections (OI).

• Support treatment as prevention.

• Support universal coverage and access to quality ART and comprehensive care and treatment services. [PFIP]

• Pilot point of care HIV testing, CD4 testing, and viral load testing in MCH and TB sites.[PFIP]

• Provide TA to implement comprehensive care package for adult treatment and care.[PFIP]

• Provide TA to GRZ to provide HAART for eligible HIV positive pregnant women.[PFIP]

• Continue to identify efficiencies and economies of scale to allow for expanded ART coverage.

• Continue to support the access and expansion of and linkages to TB, STI, and OI within appropriate settings and USG guidelines, including the treatment for TB/STs/OIs, ensuring that better drugs are available to prevent and treat OIs.

• Continue to promote prevention with positives services, including care and nutritional support.

• Continue to support gender-based interventions aimed at reducing the burden of care placed on women.

Malaria

The President’s Malaria Initiative (PMI) is a core component of the GHI, along with HIV/AIDS, and tuberculosis. The activities that PMI is proposing to support fit in well with the National Malaria Strategic Plan (NMSP) and build on investments made by PMI and other partners to improve and expand malaria-related services, including the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) malaria grants. By the end of 2014, PMI will have supported indoor residual spraying (IRS) in over 800,000 targeted houses in 2035 districts in Zambia expecting to protect over four million people.

11. Activities for the Prevention of Malaria:

• Purchase long lasting insecticidal nets (LLINs) and distribute these and other nets free-of-charge through ANC clinics and the Zambian Anglican Council (ZAC), with assistance from Peace Corps Volunteers (PCV).

• Support procurement of insecticides, personal protective equipment and other supplies for IRS.

• Train sprayers.

• Conduct an environmental assessment.

• Provide pregnant women in each of the nine provinces with two or more doses of Intermittent Preventive Treatment (IPtp).

• Increase demand for and delivery of IPTp through strengthened focused antenatal care (FANC).

12. Activities for Malaria Case Management include:

• Procure rapid diagnostic tests (RDTs) and improve laboratory diagnostic capacity, thereby assisting the NMCP in its goal of confirming every case of malaria before treatment.

• Expand malaria diagnostics support in all nine provinces by providing outreach training and supportive supervision in >100 health facilities.

• Procure ACT treatments to ensure a continuous supply to all public health care facilities.

• Train community health workers (CHWs) in targeted districts in community-based malaria interventions, such as proper use of RDTs and the ability to administer ACTs as appropriate.

• Train health workers in targeted districts in evidence-based clinical guidelines.

TB:

USAID has made a firm commitment to conduct a prevalence survey to accurately determine the number of TB cases within the country. USAID will support Zambia’s goals of identifying 90 percent of the estimated 61,000 new cases of TB, successfully treating at least 90 percent of all identified TB cases, and testing at least 90 percent of all the identified…