Attachment_J.19_-_Initial_Environmental_examination.pdf

Sensitive But Unclassified

INITIAL ENVIRONMENTAL EXAMINATION

REQUEST FOR CATEGORICAL EXCLUSION

Country/Region: Uganda / East Africa Program/Activity Number: Development Objective (DO) 3 / Intermediate Result (IR) 3.1 Program /Activity Title: Improved Health and Nutrition Status in Focus Areas and Population Groups / More Effective Use of Sustainable Health Services

Functional Objective: 3 Investing in People Program Area: 3.1 Health Program Elements: 3.1.1 HIV/AIDS

3.1.2 Tuberculosis

3.1.3 Malaria

3.1.6 Maternal and Child Health

3.1.7 Family Planning and Reproductive Health

3.1.8 Water Supply and Sanitation

3.1.9 Nutrition

Funding Period: January 1, 2016 to September 30, 2021

LOP Amount: Estimated at $2,500,000,000 (flatline scenario over 5 years) Sub- Activities/Amounts:

1. Indoor Residual Spraying (IRS-II): $88,831,827

2. TBD – Malaria Action Program for Districts (MAPD): $45,000,000

3. Deliver Project Task Order 7: 51,462,373

4. Centers for Disease Control Interagency Agreement (CDC IAA) : 2,750,000

5. Strengthening TB and HIV/AIDS Response in the South Western Region of Uganda

(STAR):

a. East Central: $54,999,939

b. East: $63,701,157

6. Targeted HIV/AIDs and Lab Services (THALAS): $19,800,000

7. Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN):

$58,246,424

8. Monitoring and Evaluation Emergency Plan Program (MEEPP II): $12,250,816

9. Strengthening Human Resources for Health (SHRH): $23,000,000

10. Strengthening Decentralization for Sustainability (SDS): $54,990,271

11. TBD – Strengthening Decentralization for Sustainability (SDS) Follow-on:

$50,000,000

12. Private Health Support (PHS): $23,500,000

13. Communication for Healthy Communities (CHC): $49,997,475

14. Advocacy for Better Health: $19,980,735

15. Uganda Health Supply Chain Project (UHSC): $29,900,000

16. Strengthening Uganda’s Systems for Treating AIDS Nationally (TRACK TB):

$12,275,135

17. Applying Sciences to Strengthen and Improve Systems (ASSIST): $15,000,000

18. Regional Health Integration to Enhance Services (RHITES)

a. East Central: $57,067,000

b. East: $54,925,000

c. Southwest: $59,637,000

d. North-Achioli: $35,000,000

e. North-Lango: $35,000,000

19. Social Marketing Activity: $16,000,000

20. Strategic Information Technical Support Project (SITSP): $15,000,000

21. Long Term Methods Family Planning (LTM): $20,000,000

22. Long Term Methods Family Planning follow-on (LTM-II): $60,000,000

23. Reproductive Health Vouchers Program (RHVP): $24,500,000

24. Saving Mothers, Giving Life (SMGL) Construction, A&E: $4,400,000

25. Advancing Partners and Communities (APC): $5,000,000

26. Fistula Care Plus: $5,000,000

27. Maternal and Child Survival Program (MCSP): $10,000,000

28. Uganda Demographic and Health Survey (UDHS): $5,000,000

29. Comprehensive HIV/AIDS and Health Services at the Workplace Activity: $15,000,000

30. TBD – Site Improvement Monitoring Systems (SIMS): $15,000,000

IEE Prepared By: Chris Penders, GH/OCS, on behalf of the USAID/Uganda Health Office Current Date: January 06, 2016

IEE Expiration Date: September 30, 2021 IEE Amendment (Y/N): No

Additional References:

This IEE builds on the following USAID environmental compliance documentation that is already in effect for ongoing activities in USAID/Uganda:

• Uganda IRS Supplemental Environmental Assessment, Amendment #1 2014-2019.

Bethesda, MD. AIRS Project, Abt Associates Inc. (November 2014).

• Uganda IRS Supplemental Environmental Assessment (2010) http://gemini.info.usaid.gov/egat/envcomp/document.php?doc_id=37067

• Uganda_DO1_PERSUAP – this is for the Economic Growth D.O.:

http://gemini.info.usaid.gov/egat/envcomp/repository/doc/43631.docx

• USAID Integrated Vector Management Programs for Malaria Vector Control:

Programmatic Environmental Assessment 2012 update:

http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/39185.pdf

• Uganda DO1 FtF IEE 08132014:

http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/41076.pdf (original);

http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/43481.pdf (Amendment 1);

http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/44841.pdf (Amendment 2)

• Uganda Infrastructure Development IEE 051715:

http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/43816.pdf

• Uganda Education, Youth & Child Development (EYCD) IEE 092815 http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/45391.pdf

ENVIRONMENTAL DETERMINATION RECOMMENDED

http://gemini.info.usaid.gov/egat/envcomp/document.php?doc_id=37067 http://gemini.info.usaid.gov/egat/envcomp/repository/doc/43631.docx http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/39185.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/41076.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/43481.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/44841.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/43816.pdf http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/45391.pdf

Categorical Exclusion: X Negative Determination: X Positive Determination: None Deferral: None

ADDITIONAL ELEMENTS:

CONDITIONS: X EMMP: X ERF/ERR: X WQAP : X

SUMMARY OF FINDINGS:

The purpose of the Health Sector Initial Environmental Examination (IEE) is to provide threshold determinations for USAID/Uganda activities under Intermediate Result (IR) 3.1, More Effective Use of Sustainable Health Services, as part of Development Objective (DO) 3, Improved Health and Nutrition Status in Focus Areas and Population Groups.

This IEE consolidates threshold determinations for activities managed by the Health Office, which will be implemented in the next five years. Section 1.3 gives a description of envisaged health activities; Section 2 provides an overview of Uganda’s environment and the health sector;

Section 3 provides an evaluation of the potential environmental impacts of health activities;

Section 4 provides the threshold environmental determination and mitigation actions, monitoring and compliance assurance, and general project implementation and monitoring requirements.

RECOMMENDED THRESHOLD DETERMINATIONS:

This IEE recommends the following environmental determinations.

1) A Categorical Exclusion is recommended for: meetings, workshops, capacity building, evaluations, research, skills development and training, and providing technical assistance, among others, pursuant to 22 CFR 216.2 (c)(i).

2) A Negative Determination with Conditions per 22 CFR 216.3 (a) (2) (iii) is recommended for activities that will have no significant adverse environmental impacts with adequate mitigation and monitoring, this include the following activities:

a) Activities that generate Health Care Waste (HCW)

b) Water, Sanitation and Hygiene (WASH)

c) Indoor Residual Spraying (IRS)

d) Long Lasting Insecticide-treated Bed Nets (LLINs)

e) Procurement, storage, management and disposal of public health commodities

f) Construction and Renovation (C&R)

g) Nutrition commodity management including packaging, warehousing and distribution

No. Activities Categorical Exclusion

Negative Determination with Conditions

Positive Determination

Deferral

1 Indoor Residual Spraying (IRS-II) X X -- -- 2 TBD – Malaria Action Plan for

Districts (MAPD) X X -- --

3 Deliver Project Task Order 7 X X -- -- 4 CDC IAA for UMSP and TA X X -- --

5 STAR- EC, E, RHITES SW X X -- --

6 THALAS X X -- --

7 SUSTAIN X X -- --

No. Activities Categorical Exclusion

Negative Determination with Conditions

Positive Determination

Deferral

8 MEEPP II X -- -- --

9 Strengthening Human Resources for

Health (SHRH) X -- -- --

10 Strengthening Decentralization for Sustainability (SDS)

X X -- --

11 TBD – SDS Follow-on X X -- -- 12 Private Health Support (PHS) X X -- -- 13 Communication for Healthy

Communities (CHC) X -- -- --

14 Advocacy for Better Health X -- -- -- 15 Uganda Health Supply Chain Project

(UHSC)

X X -- --

16 TRACK TB X X -- --

17 ASSIST X X -- --

18 RHITES – EC, E, SW, N-A, N-L

Regions X X -- --

19 Social Marketing Activity X -- -- -- 20 Strategic Information Technical

Support Project (SITSP) X -- -- --

21 Long Term Methods Family Planning (LTM)

X X -- --

22 Long Term Methods Family Planning follow-on (LTM-II)

X X -- --

23 Reproductive Health Vouchers Program (RHVP)

X X -- --

24 Saving Mothers, Giving Life (SMGL) Construction, A&E

X X -- --

25 Advancing Partners and Communities (APC)

X X -- --

26 Fistula Care Plus X X -- -- 27 Maternal and Child Survival

Program (MCSP) X X -- --

28 Uganda Demographic and Health Survey (UDHS)

X -- -- --

29 Comprehensive HIV/AIDS and Health Services at the Workplace Activity

X X -- --

30 TBD – Site Improvement Monitoring Systems (SIMS)

X -- -- --

Activities with a Negative Determination with Conditions require the development of an Environment Monitoring and Mitigation Plan (EMMP) which identifies the IEE conditions and mitigation measures for each activity that will have an adverse effect on the environment.

Environmental Responsibilities:

As required by ADS 204.3.4, USAID/Uganda Health Office and activity implementing partners will actively monitor and evaluate whether the environmental features designed for these Health activities resulting from the 22 CFR 216 process are being implemented effectively and whether there are new or unforeseen consequences arising during implementation, that were not identified and reviewed in accordance with 22 CFR 216. If additional Health activities not described in this document are added, an amended environmental examination must be prepared and approved.

In the event that any new Health activity differs, substantially from the type or nature of activities describes here or require different or additional mitigation measures beyond these described, this IEE will be amended.

INITIAL ENVIRONMENTAL EXAMINATION

Region: Uganda/ East Africa.

Program/Activity Number: Development Objective (DO) 3 / Intermediate Result (IR) 3.1 Program /Activity Title: Improved Health and Nutrition Status in Focus Areas and Population Functional Objective: 3 Investing in People

1.0 BACKGROUND AND ACTIVITY DESCRIPTION:

1.1 Purpose and Scope of Initial Environmental Examination (IEE):

The purpose of this IEE is to provide threshold determinations for the existing and new Development Assistance (DA) programming activities in Health, in accordance with the requirements of Regulation 22 CFR 216, This document will assist in ensuring environmental compliance, and will permit the implementation of the proposed DA funded program activities in accordance with USAID Environmental Policy and Procedures (22 CFR Part 216).

This IEE provides the first review of the reasonably foreseeable effects on the environment of the proposed development interventions and activities in the Health portfolio. Activities that are integrated with other sectors, including agriculture and health, are cross-referenced to existing relevant USAID/Uganda IEEs and other environmental documentation.

This IEE consolidates the threshold determinations for all activities currently envisioned under the Health portfolio and partially replaces the DO3: Investing in People (Health), Blanket IEE developed in 2009 which expires on December 31, 2015. This IEE replaces the expiring IEE and will cover the period from January 1, 2016 through September 30, 2020.

In the event that any new proposed activity in Health differs substantially from the type or nature of activities described here or requires different or additional mitigation measures beyond these described, this IEE will be amended.

Ongoing activities operating with an approved environmental mitigation and monitoring plan (EMMP) conforming to the requirements of the IEE “Uganda_FY08_SO9_IEE_092408” may continue operating under that approved EMMP. Ongoing activities without an approved environmental mitigation and monitoring plan (EMMP) are required to prepare and have approved an EMMP based on this IEE in a timely manner.

1.2 Background:

In spite of decades of substantial international support, Uganda’s health, population, education and income conditions remain worrisome. Meanwhile, Government of Uganda (GOU) budget allocations to Uganda’s social sectors have declined, from 40 percent of total budget allocations in 1998 to about 28 percent in the current budget. While many basic indicators of health continue to stagnate, the World Health Organization (WHO) cites that health sector funding from the GOU remains inadequate at 10.2 percent of general government expenditures. Continued http://gemini.info.usaid.gov/egat/envcomp/repository/pdf/666.pdf widespread official corruption and mismanagement, combined with a growing trend toward diminished respect for civil and human rights, are impeding progress in the health sector.

In response to these challenging conditions, the USAID/Uganda Health Office has developed a comprehensive approach to address Development Objective (DO) 3 on health and education, Intermediate Result (IR) 3.1: More Effective Use of Sustainable Health Services.

1.3 Description of Activities:

As described fully in the USAID/Uganda Project Appraisal Document (PAD) More Effective Use of Sustainable Health Services (2013), USAID is focusing efforts in the following three areas (sub-IRs):

1. Strengthening health systems;

2. Improving accessibility to quality health services; and

3. Increasing health seeking behaviors and demand for quality services.

Expected outcomes under the above sub-IRs include:

• Functional enabling environment and partnerships to implement sector policies, regulations and strategies;

• Increased availability of resources for public and private sector health services;

• Improved organization and management of service delivery;

• Increased availability and accessibility to health services;

• Improved quality of health services; and

• Increased adoption of healthy behaviors by communities in focus areas and target populations.

The USAID/Uganda Health Office has developed a set of activities that seek to address the myriad of challenges confronting the health sector. Activities vary in size and scope, and may address multiple sub-IRs or be designed to target specific obstacles within a sub-IR. Each of these activities is described below.

1. Indoor Residual Spraying (IRS-II) The goal of IRS-II is to contribute to effective use of social sector services through three main objectives: (1) implementation of a high quality, safe and effective IRS program; (2) developing the national capacity to conduct IRS and; (3) conducting comprehensive monitoring and evaluation of the IRS program. The project objectives will be achieved through the following IRs:

1.1 IRS programs planned in collaboration with the NMCP/MOH, districts and other stakeholders;

1.2 Develop sufficient program infrastructure, skills and information, to effectively manage the IRS program;

1.3 Ensure quality management of operational, technical and financial elements of the program;

2.1 Provide National and District level trainings and technical assistance on IRS related activities;

2.2 In collaboration with the NMCP/MOH, participation from stakeholders for IRS established;

2.3 Cost-effective innovations for the IRS program efficiently implemented;

3.1 Develop and implement IRS program management and performance monitoring plans.

2. Malaria Action Plan for Districts (MAPD) [Not listed in the FY15 OP] This activity seeks to build on already experienced, existing service delivery platforms to integrate the delivery of health care services, and organize project implementation through a combination of regionally based health service delivery programs. Supportive supervision is provided by integrated, regional teams and high-level, centrally supported, cross-cutting programs to strengthen health systems.

3. Deliver Project Task Order 7 for Malaria [From OP] The availability of essential malaria commodities such as long-lasting insecticide-treated bed nets (LLINs), Artemesinin-based Combination Therapies (ACTs), Artesunate injectable for severe malaria and rapid diagnostics test kits is critical to implementation of President’s Malaria Initiative programs. Through this mechanism, USAID will procure essential malaria commodities both for the private-not-for-profit and public sector. The purpose of this funding is to increase availability and access to these essential commodities to reduce malaria-related morbidity and mortality in the country.

4. Centers for Disease Control Inter-Agency Agreement (IAA) [From OP] The IAA with CDC was established to provide technical assistance to the President’s Malaria Initiative (PMI) and the GOU. The objectives for CDC are to:

1. Support the Uganda Malaria Surveillance Project (UMSP) to strengthen and expand malaria reference centers to improve surveillance and malaria diagnostic capacity, conduct drug efficacy studies, and support monitoring activities. CDC will train clinicians and laboratory technicians on improved diagnostics, treatment, and data reporting.

2. Fund the senior PMI technical adviser at CDC Uganda, whose role is to provide TA to the GOU’s malaria program.

3. Provide short-term TA from CDC Atlanta to train GOU environmental compliance officers, support the indoor residual spraying program in conducting effective entomological monitoring, and provide guidance to the PMI team.

4. Support the field epidemiology and laboratory training program, which places two epidemiologists at the MOH.

5. STAR – East Central (EC), East (E), and RHITES SW The goal of the STAR activities – STAR-EC, STAR-E and STAR-SW – are to increase access to, coverage of, and utilization of quality comprehensive HIV/AIDS and TB prevention, care and treatment services in district health facilities and communities in the East Central, East and Southwest regions. Key objectives include: (1) strengthening decentralized HIV/AIDS and TB service delivery systems with emphasis on level III and IV health centers (HCs) and community outreach; (2) improving quality and efficiency of HIV/AIDS and TB service delivery; (3) 3trengthening networks and referral systems; and (4) intensifying demand for HIV/AIDS and TB services. Key populations targeted include sex workers and their partners, men who have sex with men (MSM), and other vulnerable populations (fisher-folk, migrant workers, motorcyclists, couples and truck drivers). Activities include: promotion of high impact prevention interventions, voluntary medical male circumcision (VMMC), prevention of mother-to-child transmission (PMTCT), condom use, HIV testing and counseling (HTC), care and support, pediatric and adult antiretroviral therapy, TB/HIV co-management and lab support. STAR-EC/E will utilize lessons learned to scale up high impact interventions and improve access for key populations and those in hard-to-reach areas. In partnership with districts and civil society organizations, STAR-EC/E will focus on quality improvement and capacity building in lab services and pharmaceutical management, and on strengthening coordination structures & partnerships to enhance sustainability. Monitoring and evaluation (M&E) will be accomplished using available national data, data from lot quality assurance sampling (LQAS) surveys, and data from routine reports.

6. Targeted HIV/AIDS Lab Services (THALAS) The main goal of the THALAS program is to increase access to, coverage of, and utilization of quality comprehensive HIV/AIDS and tuberculosis care and treatment services; provide advanced HIV/AIDS care and treatment services for complicated cases referred from other HIV/AIDS care and treatment providers; and provide HIV diagnosis and monitoring services including viral load (VL) testing and DNA PCR for early infant diagnosis (EID). The EID service has been fully transitioned to Central Public Health Laboratories (CPHL). THALAS provides clinical care and adult and pediatric ART services. The project also provides HIV/AIDS routine laboratory monitoring and VL testing for patients. THALAS trains lab staff in manual and automated testing techniques and resident mentors at regional referral and general hospitals enhance delivery of quality services. THALAS supports resident mentors through THALAS preceptors and laboratory quality improvement (QI) teams. THALAS supports capacity building and provides technical assistance for Ministry of Health (MoH) laboratories that enhance quality of lab services. THALAS will continue to scale up HIV/AIDS care and treatment services, implement the revised MoH treatment guidelines, support national laboratory QI practices, and support MoH/CPHL in scaling up lab quality management practices.

7. SUSTAIN

SUSTAIN aims to provide quality HIV prevention, care and treatment services and TB/HIV services at selected regional referral and district hospitals in Uganda while simultaneously building their capacity to provide these services. This goal is pursued through training of health workers; improvement of laboratory infrastructure and equipment to enhance HIV/AIDS diagnosis and disease monitoring; developing systems for financial, human resources and logistics management; as well as quality assurance and improvement. The program is implemented in 19 hospitals (12 regional referral hospitals, 5 general hospitals and 2 level IV health centers). SUSTAIN has successfully integrated the previously vertical HIV clinical and laboratory services into the public health care system with up to 42,151 clients active on ART and 52,605 in care. SUSTAIN has also refurbished and equipped 17 regional referral and general hospital laboratories and elevated them to regional hubs for the Ministry of Health (MoH) laboratory sample transportation network. SUSTAIN activities include technical support in HIV/AIDS prevention, care and treatment, upgrading laboratories, establishing drug-resistant TB treatment centers and continued support to MoH laboratory hubs that support lower level laboratories around the country. Seven MoH regional medical equipment workshops will be upgraded, equipped and given routine support to effectively provide maintenance, repair and servicing of biomedical equipment in healthcare facilities across the country.

8. Monitoring and Evaluation of Emergency Plan Progress – Phase II (MEEPP-II) The overall goal of the MEEPP-II project is to strengthen HIV/AIDS-related national monitoring and evaluation systems and support the collection of complete, accurate, and timely data that can meet Government of Uganda (GoU), PEPFAR, Global Fund, and other development partner data requirements. The primary objective of MEEPP-II is to shift from a vertical and comprehensive PEPFAR implementing partner (IP)-based program performance management system and strengthen the existing national and district-level monitoring and evaluation (M&E) systems to support data needs of the key HIV/AIDS-related stakeholders. These stakeholders include the Ministry of Health (MoH); Ministry of Gender, Labour and Social Development (MGLSD);

PEPFAR; Global Fund; UNAIDS; WHO; UNICEF; and other development partners. To achieve its primary objective, MEEPP-II has developed and implemented collaborative strategies engaging PEPFAR USG agencies and their respective implementing partners, the USG activity managers, as well as GoU national-level stakeholders, including MoH/Resource Center (RC), MoH/National AIDS Control Program (NACP), MGLSD/Orphans and Other Vulnerable Children (OVC) National Implementation Unit and the Ugandan AIDS Commission (UAC).

MEEPP-II is the main vehicle for the implementation of PEPFAR Strategic Information (SI) Pivot 1 - “Alignment of USG-supported systems with the national information systems”, and also supports Pivot 2 - “Support robust M&E systems at service delivery points and districts", and Pivot 3 - “Increase use of data for evidence-based planning and decision making at all levels”.

9. Strengthening Human Resources for Health (SHRH) SHRH is a bilateral associate award under the Capacity Plus LWA. Building upon the Uganda Capacity Program and continuing human resources for health interventions which were shown to produce higher level results, SHRH will further expand in the area of pre-service training capacity and performance based incentives. SHRH will develop the capacities of the central ministries, districts and professional councils to effectively and efficiently manage their HR for delivery of health services. It will work with USG implementing partners to ensure targeted HRH improvements at the service delivery level. Expected results include the scale up of HR information system and recruitment plans in all 112 districts, comprehensive support for district level HRH to all USG implementing partners, and improved regulation and functionality of health professional councils.

10. Strengthening Decentralization for Sustainability (SDS) The SDS activity aims to improve results and sustainability of decentralized service delivery in health and HIV at local government levels in 50 districts by: strengthening coordination, program resource management at district and sub-county levels; improving local government support for service delivery through grants; and instituting innovative approaches to sustain service delivery. SDS will continue to disburse service delivery grants for HIV services; Malaria and MNCH interventions including support for community outreach to mobilize women for antenatal and post natal care, supporting skilled attendance at delivery, immunization outreach and provision of short- and long-term term family planning methods and services. HIV services include VMMC, PMTCT, HIV care and treatment and health care waste management. SDS will continue to support HIV services, human resources for health, governance and leadership at district level, and construction of laboratory hubs and WASH facilities.

11. TBD – SDS follow-on USAID anticipates awarding a systems strengthening program as a follow on to the SDS program in FY 17. The overall goal of the project will be to support key systems elements at national and sub-national level that are critical for improved and quality services.

Key areas of support may include granting to districts, human resources for health, health financing and decentralized governance support. Although not yet awarded, some of the support may entail providing grants for waste management, and construction.

12. Private Health Support (PHS) Program The PHS program aims to strengthen, organize and mobilize the private sector to provide Ugandans with the option of obtaining high-quality health services from private for profit (PFP) providers. The program's objectives are to: a) expand availability of health services by private providers; b) increase affordability of private health services and products; and c) improve quality of private health sector facilities and services. The program supports 120 private providers in approximately 44 districts of Uganda targeting clients of PFP facilities as well as workplace sites. The project will facilitate partnerships and provide technical assistance to design and implement comprehensive workplace health programs that maximize accessibility to tuberculosis; maternal, newborn and child health; family planning; nutrition; and malaria prevention and treatment services.

13. Communication for Healthy Communities (CHC) The CHC project builds on previous work by the Government, Health Communication Partnership (HCP) project and other implementing partners. The main purpose of CHC is to increase to adoption of healthy behaviors, including uptake of high impact interventions, through strengthened health communication. The goal will be achieved through three key results: (1) high quality health communication interventions designed and implemented; (2) improved coordination of health communication interventions; and 3) increased research and knowledge management to enhance health communication. CHC will work with stakeholders to raise the quality, consistency and availability of HIV education and promotion materials. CHC will adapt and scale up evidence- and theory-based health communication interventions to support service delivery activities at the community level as well as address the key program strategic pivots. As part of their formative research, CHC, will undertake gender analysis, including the extent to which gender issues are affecting uptake of services and if existing strategies and materials are addressing these issues. CHC will work closely with key stakeholders to identify and implement context-appropriate, cost-effective, and reliable data collection processes that can be used by the GoU and partners for effective planning and assessment of health outcomes and impact.

14. Advocacy for Better Health The goal of Advocacy for Better Health is to empower communities in 35 districts, including 13 focus districts, and strengthen advocacy initiatives that will contribute to improved quality, availability and accessibility of health and social services. The program will increase citizens’ voices and develop the roles of communities and community organizations in planning, delivery, and monitoring services and results. The program will target the general population in communities within particular districts and sub-counties and community leaders, health care providers, and vulnerable populations, including caregivers and women. The program will engage with other USAID partners and private sector, and will enable civil society organizations (CSOs) to advocate for issues that can improve programs and policy environments. The program will complement ongoing system strengthening interventions by other district-based technical assistance programs and will leverage resources. The activity is expected to build capacity of at least 4 CSOs in effective advocacy and to ensure that project results and outcomes are sustained beyond the life of this program. The activity will develop and maintain a performance monitoring system including a Performance Management Plan (PMP) and results framework.

Monitoring will be through quarterly reports and site visits. The program will share lessons, document emerging issues and draw lessons for more effective implementation and focused results. Possible areas for advocacy include: better functioning of Global Fund resources;

demand generation in support for eMTCT; and better and increased resource allocation for HIV and social services for orphans and vulnerable children by government.

15. Uganda Health Supply Chain (UHSC) SSHC aims to increase the availability, accessibility and appropriate use of essential medicines and health supplies (EMHS) through reform of national policies and strategies to maximize efficiency, transparency and equity in use of EMHS resources and country capacity building for effective management of supply chain operations including key support towards warehousing and facility storage infrastructure improvements. Expected results include development of country capacity improvement and transition plan; initiation of action on improving access to life-saving medicines for women and children; expansion of performance assessment, supervision and reporting system nationally; progress in designing and implementation of integrated logistics management information system for improved data availability at all levels;

and continued progress in integrating health commodity management in pre-service curricula.

16. TRACK TB

The TRACK TB project supports the Ministry of Health (MoH)/National TB Leprosy Programme (NTLP) to improve case detection and treatment success rates. The project aims to enhance NTLP leadership and technical capacity for planning, monitoring, and implementation of TB control activities; implement an effective urban community-based DOTS model;

implement a high-quality program for the management of MDR TB; improve coordination and implementation of DOTS, TB/HIV, and community-based MDR TB interventions with USAID TB programs. Direct service delivery targets the 5 divisions of Kampala district. TRACK TB provides TB/HIV services in partnership with district local governments and the MoH. This will foster implementation of sustainable innovative approaches, expansion of quality services, and effective program management systems. TRACK TB will focus on use of efficient cost-effective approaches such as on-the-job training, continuous quality improvement approaches, supportive supervision and mentorships to reduce program costs and monitor and improve quality of TB/HIV services. The TB/HIV comprehensive service package at supported health facilities will include: the three “I’s” (intensified case finding, infection control and isoniazid preventive therapy), strengthening TB/HIV integration, community-based directly observed treatment, short-course, TB patients receiving provider-initiated testing and counseling, TB/HIV co-infected patients receiving cotrimoxazole prophylaxis and antiretroviral therapy, scale-up of pediatric TB/HIV and programmatic management of multi-drug resistant. Monitoring and evaluation plans include tracking progress towards meeting objectives through use of available national data, routine quarterly reports to USAID, and PEPFAR semi-annual and annual reporting.

17. Applying Science to Strengthen and Improve Systems (ASSIST) The ASSIST project is a field support mechanism which aims to: build capacity of USG partners to improve the quality of HIV/AIDS, TB/HIV, nutrition, and Orphans and other Vulnerable Children (OVC) services; build capacity of Ministry of Health (MoH) and Ministry of Gender, Labor and Social Development (MGLSD) to coordinate and oversee implementation of national quality improvement plans and strategies; and to generate new knowledge and best practices in quality improvement as part of a continuous learning and adapting agenda. The ASSIST project will:

1. Support and strengthen MoH and its Quality Assurance Department to coordinate and oversee the implementation of the national health sector quality improvement framework and strategy;

2. ASSIST will support MGLSD, its district structures, and other OVC partners to roll out and institutionalize the national OVC quality assessment, improvement and assurance tools;

3. Provide technical assistance and capacity building to all USG implementing partners, including private sector partners, to scale-up quality improvement interventions in supported districts and expand QI approaches to at least, but not limited to, four program areas: voluntary medical male circumcision (VMMC), TB/HIV, Prevention of Mother-to-Child Transmission (PMTCT) and OVC; and

4. Test a range of quality improvement interventions in selected sites to generate new knowledge and evidence-based best practices to be disseminated to all partners as part of a collaborating, learning and adapting agenda.

18. Regional Health Integration to Enhance Services (RHITES) in East Central (EC), Eastern (E), Southwest (SW), Northern-Achioli District (N-A) and Northern-Lango District (N-L)

The RHITES EC, E, SW, N-A and N-L activities will replace the STAR program. RHITES supports a comprehensive and integrated regional health, HIV/AIDS and nutrition assistance activity. RHITES builds on the successes of the STAR program by continuing to improve quality and efficiency of HIV/TB services within health facilities and community service organizations and groups in targeted districts and will strengthen networks and referral systems to improve access to, coverage of and utilization of HIV and TB services, while intensifying demand generation activities for prevention, care and treatment services. RHITES will also extend support to other health areas, including maternal, newborn and child health, family planning and nutrition services, in targeted districts, as well as to approaches that strengthen the district health system’s leadership and ownership of services. This activity will work collaboratively with national and district partners to strengthen health systems in targeted districts. Health systems of particular note include, but are not limited to, human resources, supply chain management, laboratory support leadership, management, Health Management Information System (HMIS), strategic information and infrastructure. RHITES will support the MoH to continue to scale up high impact, evidence-based HIV/AIDS prevention, care and treatment interventions in the East, East Central, Southwestern regions and in the Achioli and Lango districts in Northern Uganda.

19. Social Marketing Activity The goal for the Social Marketing activity is to improve availability and utilization of social marketing products and services among target populations in rural and urban areas. The three key result areas for this project are: (1) increased access to quality and affordable health products and services; (2) increased demand among target population for socially marketed products and services; and (3) strengthened systems for sustained, equitable access to health products and services. Social Marketing was identified as a key pivot to increasing condom awareness and use among key and other vulnerable populations and in the general population. This activity will promote positive behavior change through various innovative and proven methods, and ensure widespread access to affordable high-quality products and services. Products will include condoms, contraceptives, and mosquito nets, among others, while services will include family planning and condom use, among others. This mechanism will address underlying gender issues that affect participation and access by men, boys, women and girls to the different services of the program. This activity offers an opportunity to enhance HIV and family planning service integration. In addition to measuring performance through the Performance Management Plan, this activity will undertake annual periodic assessments on and analyses such as satisfaction surveys, willingness to pay studies, and market audits that can quantify the increased contribution of social marketing approaches within the health service delivery space.

20. Strategic Information Technical Support Project (SITSP) SITSP is the lead M&E activity for the health strategy, providing M&E and strategic information technical assistance and SI systems strengthening to USAID, implementing partners, Government of Uganda and supported health facilities and community sites. This project will consolidate several SI activities currently implemented by multiple partners, including: (1) an Annual Health Facility Assessment; (2) monitoring health services outcomes using Lot Quality Assurance Sampling (LQAS) methodology; (3) data quality improvement and reporting for Health Programs; (4) strengthening M&E Capacity at national, district, health facility and community levels; and (5) supporting the country-led Health Management Information Systems (HMIS) at all levels. These activities are aimed at increasing the use of data for evidence-based decision-making at the various levels.

21. Long Term Methods for Family Planning (LTM) The objective of the LTM activity is to increase access to long term and permanent family planning methods in Uganda. In partnership with DFID, LTM aims to achieve the following:

expanding access to and the range of services; integrating HIV testing and cervical cancer screening; and strengthening the national health system by embedding dedicated providers (DP) at high traffic hospital-level public or Private Not-For-Profit (PNFP) health facilities. DPs will provide services and improve the ability of host facilities to sustainably provide services through mentoring, improving stock management, integrating FP into day-to-day activities, and engaging district leadership.

22. Long Term Methods for Family Planning follow-on (LTM-II) LTM-II is a bridge activity using $9M from USAID and $11M from DFID between the Expanding Access to Long Term and Permanent Methods (LAPM) for FP program and its follow-on. It will increase the breadth and depth of FP service delivery in Uganda through: (1) expanding geographic coverage and reach of FP services; (2) increasing affordability, particularly the provision of LAPM; (3) strengthening the capacity of the public sector to deliver LAPM; and 4) integrating reproductive health services with HIV testing, STI treatment, and cervical cancer screening (CCS). DPs will provide services and improve the ability of host facilities to sustainably provide services through mentoring, improving stock management, integrating FP into day-to-day activities, and engaging district leadership.

23. Reproductive Health Voucher Program (RHVP) USAID will complement the new SIDA/World Bank RHVP to increase access among poor women to skilled care during pregnancy, delivery, and postpartum. The project will support:

pregnant women to deliver under skilled attendance; pregnant women to attend at least 4 antenatal care (ANC) visits; women with HIV to receive PMTCT; and mothers to access post-natal care. The safe delivery component provides subsidized vouchers to poor pregnant women to access a package of safe delivery services from contracted service providers. The package will also include prevention of mother-to-child transmission and malaria prevention services as part of ANC. Capacity building and project management will support project management functions and build national capacity to mainstream and scale-up implementation of the voucher scheme in the health sector.

24. Saving Mothers, Giving Life (SMGL) Construction, A&E The SMGL Phase II program is scaling up in six districts in Northern Uganda. An integral part of the program is ensuring that health facilities are fully functional and in position to provide both basic and comprehensive emergency obstetric and newborn care. As a lesson learned from the SMGL phase I, renovations and minimal construction of some physical structures in select health facilities, especially level IV health centers and hospitals – in addition to staff recruitment

– made them attain full functionality to manage obstetric complications. Funds will be used to buy into the East Africa Construction IQC to renovate/construct: (1) operating theatres; (2) delivery rooms; (3) neonatal units; (4) medical waste disposal areas, such as incinerators; (5) water; and (6) lighting systems.

25. Advancing Partners and Communities (APC) APC will expand community based family planning (CBFP) with system strengthening at national and district levels, and provision of direct service delivery. APC aims to achieve five objectives: (1) increasing access to FP at community level; (2) strengthening supportive systems and structures at district and national levels to advance CBFP; (3) advocacy for inclusion of drug shops in the continuum of FP service delivery; (4) provision of CBFP/reproductive health services and information to youth; and (5) working with relevant HIV/AIDS implementing partners in project sites to integrate FP within PMTCT services. APC will build on past USAID investments such as the GREAT project, Uganda Community Connector and PROGRESS projects. APC will add innovations in FP technology, such as Sayana Press, to the method mix of FP/RH commodities.

26. Fistula Care Plus [From OP] Building on the successes of Fistula Care, the Fistula Care plus project will continue to address and scale up obstetric fistula prevention and repair through reintegration activities in support of the goal of integrating services to enhance linkages and leverage MNCH and FP programs.

Deliberate steps will be taken to work with private sector and/or civil society to support treatment advocacy, rehabilitation and further engaging government institutions and systems.

The project will bring on board Lacor Hospital (faith-based) in Northern Uganda and Jinja Hospital (public) in Eastern Uganda to address equity in service delivery. USAID will continue to transform the lives of women living with fistula and work to address the underlying causes by working together with other partners and key stakeholders in harmonizing fistula support to the

GOU.

27. Maternal Child Survival Program (MCSP) [From OP] MCSP, a field support mechanism, focuses on strengthening the immunization program in Uganda in order to improve routine immunization, at the central level MOH and in selected districts. At the central level, MCSP will strengthen the planning and management of immunization, focusing on improving data quality, performance tracking and development of data tools. At district level, support will be provided to approximately 20 districts for training, supportive supervision, demand generation and data management, while ensuring integration of immunization into other health programs. The project will expand the promising work on Reaching Every Child – Quality Improvement (REC-QI) and explore possible solutions to bottlenecks to successful REC implementation by answering certain program learning questions, introducing innovations, and working with other stakeholders.

28. Uganda Demographic and Health Survey (UDHS) [From OP] The Uganda Bureau of Statistics will conduct the sixth UDHS in 2016 with preparatory activities beginning in 2015. The UDHS will provide policy makers with information to plan future interventions effectively. Specific objectives include:

• Provision of data at the national and subnational level that will allow the calculation of demographic rates, particularly fertility and infant mortality rates;

• Analysis of direct and indirect factors that determine the level of and trends in fertility and mortality;

• Measurement of the level of contraceptive knowledge and practice of women and men by method, by urban-rural residence, and by region;

• Collection of data on knowledge and attitudes of women and men about sexually transmitted infections and HIV/AIDS, and condom use;

• Assessment of the nutritional status of children under age five;

• Measurement of key education indicators; and

• Collection of information on the extent of gender-based violence.

29. Comprehensive HIV/AIDS and Health Services at the Workplace Activity [From OP] This mechanism will support delivery of comprehensive HIV/AIDS and health services in the workplace. This activity’s target population is the Uganda Police Force, private guards from security companies with a national coverage, Uganda Wildlife Authority Staff including game rangers and park wardens, other national park staff, staff in selected hotels under Uganda Hotel Owners Association, their families and surrounding communities. This activity will support

MNCH interventions that include: support for police barracks and outposts outreaches to mobilize women for ANC/PNC, supporting skilled attended delivery, and immunization outreach activities and provision of both long term and short term family planning services. The activity will also support targeted nutrition and water and sanitation activities among the target population for better health outcomes.

30. TBD – Site Improvement Monitoring Systems (SIMS) USAID aims to improve on capacity to effectively monitor services supported through its implementing partners to both public and private institutions. SIMS is a platform that will allow for monitoring adherence to minimum quality standards of care and services across all USAID supported sites at national, regional, district, facility and community level. Expected results include improved quality management and care of all services including HIV/AIDS, maternal, neonatal, child health, malaria and family planning, as per accepted standards of care.

2.0 COUNTRY AND ENVIRONMENTAL INFORMATION (BASELINE

INFORMATION):

2.1 Locations Affected:

Activities implemented by the Health Office take place throughout the country and a variety of environmental situations may be encountered. Currently, the programs listed in Section 1.3 (see above) target 61 of the 112 health districts in Uganda, as well as national level activities with the central MOH and other ministries and organizations. Over the life of the PAD, USAID anticipates further refinements and adjustments to the targeted districts to ensure support is reaching those most in need, as well as being harmonized with other Mission priorities and investments by the GOU and other development partners. The country’s environmental baseline is summarized in section 2.2 below.

2.2 Environmental Baseline:

Although not a large country by African standards (241,000 km2), Uganda is among the richest countries with respect to its natural environment. The country has a wide variety of physical environmental features, ranging from tropical forests to grasslands, extensive surface drainage pattern (e.g. lakes, rivers, streams, etc.), and arid and semi-arid areas to snow-capped Rwenzori Mountains range. Nearly all the water bodies, notably Lake Victoria, cover 20 percent of the national surface area. The country has seven of Africa's 18 bio-diversity geographic regions, which is the highest concentration on the continent, and some 90 different vegetation communities.

Population increase has caused considerable adverse impacts on the environment, and the natural resource base. Forest and woodlands cover has declined rapidly in modern times, from an estimated 45 percent of land area in 1890 to around 21 percent at present. Population pressure has increased sharply and, population density per unit of land area is now more than four times higher than in 1950. Soil erosion is a serious problem in the high potential agriculture and grazing areas. It is mainly caused by poorly regulated agricultural practices, overgrazing by livestock and game, and indiscriminate deforestation. This causes land degradation, due to loss of plant nutrients from agricultural fields and grazing areas, sediment transport and sedimentation of surface waters. The surface runoff also contributes to the transportation of solid and liquid waste to surface waters, causing water contamination due to pollution.

Uganda's is an exceptionally important area for bio-diversity conservation. The natural resource base, especially its wide diversity of wildlife, is the country's greatest biological and economic asset for sustainable…