Attachment_J-9_IEE.pdf

ATTACHMENT J.9 – INITIAL ENVIRONMENTAL EXAMINATION

(attached)

THIS PAGE WAS INTENTIONALLY LEFT BLANK

INITIAL ENVIRONMENTAL EXAMINATION

OR

CATEGORICAL EXCLUSION

PROGRAM /ACTIVITY DATA:

Program /Activity Number: 687-005

Country/Region:

Madagascar, Southern Africa

Objective:

Investing in People

Program Area:

3.1 Health

Program Elements and Sub -Elements:

3.1.1 HIV/AIDS

3.1.1.02 Abstinence/Be Faithful

3.1.1.05 Condoms and Other Prevention Activities

3.1.1.09 Counseling and Testing

3.3.3.13 Other/Policy Analysis and System Strengthening

3.1.3 Malaria

3.1.3.1 Treatment with Artemisinin-based Combination Therapies (ACT)

3.1.3.2 Insecticide-Treated Nets (ITNs) to prevent Malaria

3.1.3.3 Indoor Residual Spraying (IRS) to prevent Malaria

3.1.3.4 Intermittent Preventive Treatment (IPT) of pregnant women

3.1.3.9 Host Country Strategic Information Capacity

3.1.6 Maternal and Child Health

3.1.6.01 Birth Preparedness and Maternity Services (including prenatal and post-partum care)

3.1.6.02 Treatment of Obstetric Complications and Disabilities

3.1.6.03 Newborn Care and Treatment

3.1.6.04 Other Immunizations including Polio

3.1.6.06 Maternal and Young Child Nutrition including Micronutrients

3.1.6.07 Treatment of Child Illness

3.1.6.08 Household Level Water, Sanitation, Hygiene, and Environment

3.1.6.11 Host Country Strategic Information Capacity

3.1.7 Family Planning and Reproductive Health

3.1.7.1 Service Delivery

3.1.7.2 Communication

3.1.7.3 Policy Analysis and System Strengthening

3.1.7.5 Host Country Strategic Information Capacity

3.1.8 Water Supply and Sanitation

3.1.8.1 Safe Water Access

3.1.8.2 Basic Sanitation

3.1.8.3 Water and Sanitation Policy and Governance

3.1.8.4 Sustainable Financing for Water and Sanitation Services

3.1.8.7 Host Country Strategic Information Capacity

Program /Activity Title:

Use of Selected Health Services and Products Increased and Practices Improved

Subactivity Title:

N/A

Funding Begin: FY 2008 Funding End: FY 2013

LOP Amount: $112,400,000

USAID MG HPN lEE Amendments

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Sub-Activity Amount: $

N/A

IEE Prepared By:

Tiana Razafimahatratra, MEO and Jacky Ralaiarivony, Alternate

MEO

Current Date:

June 7, 2010

IEE Amendment (Y/N): Yes, Filename & date of original IEE: 33 Madagascar3 Health Services dated on August 8, 2003 and as firstly amended on September 23, ENVIRONMENTAL ACTION RECOMMENDED: (Place X where applicable) Categorical Exclusion: _x

Negative Determination: _x Positive Determination:

Deferral:

ADDITIONAL ELEMENTS: (Place X where applicable)

CONDITIONS

x

PVO/NGO:

x

SUMMARY OF FINDINGS:

USAID/Madagascar's Core Health Program: "Use of Selected Health Services and Products Increased and Practices Improved" was granted a new five-year follow-on program from October 2008 to September 2013. Basically, the follow-on program has the same activities as the previous five years and is complemented with two new ones: Water Supply and Sanitation and Diarrhea Treatment. This umbrella IEE is an amendment of the Core USAID/Madagascar' Health Program IEE. Its purpose is to ensure that environmental consequences of the proposed activities are recognized and considered in their design, implementation and management. The findings of this IEE amendment will also assist Implementing Partners (IPs) in adopting environmental best practices in their activity designs. Specifically, this IEE amendment will (1) cover both follow on and new activities under the USAID/Madagascar's Health, Population and Nutrition (HPN) program; (2) adapt the "Foreign Assistance" framework with the USAID/Madagascar HPN Program IEE; (3) provide threshold determinations of environmental impact and conditions for mitigation, and (4) provide Environmental Compliance guidance to small/sub grants within some HPN program activities.

The HPN program activities contribute to Government of Madagascar (GOM) objectives. It includes five Program Elements: 3.1.1 HIV/AIDs, 3.1.3 Malaria, 3.1.6 Maternal and Child health, 3.1.7 Family Planning and Reproductive Health, and 3.1.8 Water Supply and Sanitation. This IEE replaces the Strategic Objective No5 IEE and is a starting point for new or continuing activities to be covered under the amended Strategic Objective Agreement (SOAG), and is intended to support the Mission Strategic Plan goal to "Expand and Improve Health Care Services". The HPN Program, broken down to Program and Sub-Elements is summarized below. Expected results include:

• Demand for Selected Health Services and Products Increased;

• Availability of Selected Services and Products Increased;

• Quality of Selected Services Improved; and

• Institutional Capacity to Implement and Evaluate Health Programs Improved.

Based on a pro-active approach, incorporation and promotion of environmental review procedures, capacity building, mitigation and monitoring/evaluation procedures to which the Mission commits itself, a Negative Determination with Conditions pursuant to 22 CFR 216.3(a)(2)(iii) is recommended for the following activities:

• Activities that propose health commodity stock management and distribution within the five program elements. Health product stock management and distribution may include people handling and working with chemical products. These people will need specific

USAID MG HPN IEE Amendments

Page 2/59 training and clear procedure manual establishing guidance on stock maintenance and handling (including transportation) of health products.

• Activities that will implement health programs. Implementation of health programs will involve waste health product disposal (such as used syringes, used cottons and gloves, etc.) that need careful management through specific training, clear procedure manual and adequate equipment.

• Activities with Micro Finance Institutions that support the development of WASH (Water Sanitation and Hygiene) loan products.

• Activities that will implement water and sanitation infrastructures. USAID or other internationally recognized guidelines, such as the USAID/AFR Environmental Guidelines for Small Scale Activities in Africa will be followed as well as Water Quality Assurance Plan will be implemented.

The Conditions for the HPN IEE are in summary:

• USAID/Madagascar will make clear that -- through contracts, cooperative agreements or grants, as may be the case -- the determinations specified in this IEE will need to be followed and that Implementing Partners must put in place appropriate systems or management tools to ensure compliance.

• A comprehensive approach to Health Care Waste Management (HCWM) and a "safe injection supplies security" should be developed in assessing the on-the ground situation and in developing accordingly a plan of action based on the AFR Environmental Guidelines for Small-Scale Activities in Africa (www.encapafrica.org ), and the Madagascar National Medical Waste Management Policy as seen in the Appendix 1.

• A formalized environmental review process for activities and sub-projects having negative determination will be followed. A key component of this review process is the use of an Environmental Screening Form (ESF) as seen in Appendix 2 to categorize activities, review and screen them for potential environmental impacts. Use of the ESF is recommended in accordance with the AFR Environmental Guidelines for Small Scale Activities in Africa (www.encapafrica.org ).

• Within the Malaria prevention program, the use of Long Lasting Insecticide Treated Materials in Madagascar is covered under a separate IEE.

This IEE does not cover pesticides related to the Indoor Residual Spraying (IRS) activities.

Conditions for IRS are covered under a separate PERSUAP.

As requested by the BEO/GH, this IEE proceeded to a more comprehensive evaluation of cumulative and long term impacts to the environment including sensitive habitats and socio economics to ensure that HPN program activities remain environmentally sound and socio-economically viable:

• Additional impact analysis was conducted as regards to the environmental habitats and species that shows that Madagascar has almost tripled its surface of its protected areas to cover the 10% of its territory as per the IUCN standard. All HPN activities under this IEE will be located outside protected areas. They will not have direct impacts on these sensitive habitats as they will be implemented at village community-based level. Instead, they will contribute to livelihood improvement through improved development alternatives that will lead to sustainable management of natural resources and biodiversity conservation.

• Focus has been given also to additional impact analysis for the Water activities. As per the National Water and Sanitation Center/Ministry of Water survey in 2008, Madagascar has about 900 billion m3 of water resources per year, composed of 350 billion m3 of surface water and 140 billion m3 of underground water. However, of the total, only 13 million m3 is utilized annually for the national potable water supply. In addition, only 10% of the 13 million m3 of potable water supply serves rural areas.

Given that Water activities under the HPN program will be very small scale initiatives

Page 3/59 that serve village of an average of 150 to 200 individuals and use manual drilling and pumping technologies, these activities will not result to cumulative negative impacts to the environment.

• Medical hazardous waste management As an example of the implementation of the EMMP related to medical hazardous waste management such as used syringes, the document as seen in Appendix 3 shows first the current practices at Community Health Worker level of environmental measures. The document outlines some excerpts of training curricula, required equipment such as sharps containers, and samples of job aids and tools for supervision and monitoring. It anticipates also opportunities for future support at health institution level and at national level once the socio-political context becomes stable to allow USAID Madagascar re-collaborate with the GOM.

As required by ADS 204.5.4, the HPN team will actively monitor ongoing activities for compliance with approved IEE recommendations, including via field visits, and modify or end activities that are not in compliance. If additional activities are added to this HPN IEE that are not described in this document, an amended environmental examination must be prepared.

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Table 1: MATRIX OF ACTIVITIES, RECOMMENDED DETERMINATIONS, AND CONDITIONS

• Mission staff and implementing partners should ensure that protocols and procedures for proper storage, management, and disposal are incorporated into mitigation plans.

• Consignees for pharmaceutical drugs will be advised to store the products according to the information provided on the manufacturer's Materials Safety Data Sheet.

• Implementing partners should make all reasonable attempts to facilitate the disposal of expired drugs.

• Commodities that become hazardous during use, or highly hazardous waste, must follow the conditions of appropriate waste management.

• Packaging and disposal of all other public health commodities will be consistent with the Environmental Guidelines for Small-Scale Activities in Africa (EGSSAA), 2nd Edition, Chapter 15: Solid Waste (www.encapafrica.org )

• Mission staff and implementing partners should ensure that conditions for appropriate management of waste will be implemented based on the National Medical Waste Management Policy as well as the Environmental Guidelines for Small-Scale Activities in Africa (EGSSAA), 2nd Edition, Chapter 8: Healthcare Waste

Page 5/59 products, condoms, etc.

Management and disposal of hazardous medical waste

Negative Determination with Conditions

Procurement management public commodities, nutrition supplements, oral rehydration products, water purification

ME=

and of health

Negative Determination with Conditions a - • 11 IN - 1 • - •

W,74mommuffirms • MIAI 0 L-1 Is] In I 16-14 IN Lap 14 1!0] @1, Improper handling, storage, and disposal of the waste generated in health care facilities can spread disease such as transmission of disease through infectious waste.

If waste is not treated in a way that destroys the microscopic disease-causing agents like

Pharmaceuticals have specific storage time and temperature requirements and may expire or lose efficacy before use.

Furthermore, insufficient controls may allow drugs beyond their expiry date to be diverted for resale to the general public.

The mismanagement of pharmaceutical waste poses significant risks to people and the environment including aquatic life, and therefore disposal is a major concern.

Burning pharmaceuticals and plastic medical supplies (including new or used condoms) at low temperatures or in open containers may result in release of toxic pollutants.

viruses, bacteria, parasites, or fungi; these agents will still be present in the waste and can enter the body through punctures and other breaks in the skin, inhalation, digestion, swallowed, and transmission by a vector organism

• People who are in direct contact with medical waste are at greatest risk. Examples include health care workers, cleaning staff, patients, visitors, waste collectors, disposal site staff, waste pickers, poor people manipulating garbage for goods search, those who knowingly or unknowingly use "recycled" contaminated syringes, needles, gloves, used cottons and condoms or otherwise come into contact with sharps, chemicals, and other health care wastes.

Mismanagement of health care waste poses considerable risks to people and the environment.

• Contamination of water supply from untreated health care waste can also have devastating effects.

The absence of proper sterilization procedures is believed to have increased the severity and size of infectious diseases outbreaks including diarrhea in certain parts of the country.

(www.encapafrica.org )

• Health workers will be provided with training and equipment related to management of wastes and safety of injection. Trainings will include risk assessment, injection safety, medical waste management and awareness raising among community surrounding health clinics.

• Injection safety includes rational use of injections, best practices and surveillance and case management of MAPI (Post Injection Adverse Reaction). Medical waste management topics include classification of medical wastes, disposing medical waste, maintenance of incinerator/ safe holes and hospital medical waste management.

• Health workers will follow procedures under the "Reference manual for Immunization Program Managers" (2007) for safety injections and waste disposal, in particular using sharp boxes.

• USAID advises against the incineration of the following types of health care waste: plastics, pressurized gas containers, large amounts of reactive chemical waste, silver salts and photographic or radiographic wastes, halogenated plastics, waste with high mercury or cadmium content (e.g., thermometers and batteries).

USAID MG HPN 1EE Amendments

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Improper open dumping and uncontrolled burning of health care waste increase the risk that infections will be spread and exposure to toxic emissions from incomplete combustion.

Incineration can create chemical pollution and public health problems. Chemicals emissions resulting from the medical waste incineration contaminate fish, meat and dairy foods. It has been proved that these chemicals ingestion have been linked to diverse diseases such as infertility, birth defects, learning disabilities, cancer...

Small grants for Negative •

Small grants typically will not have •

Since the activities under small grants are sub-projects Determination with any negative environmental often defined after the approval of this

Conditions impacts however the unknown umbrella IEE, the Mission will ensure that the nature of these activities requires Africa Bureau Environmental Review Process is a the implementation of the completed as a means of determining any Environmental Review Process. potential environmental impacts.

The full set of guidelines is at www.enca africa.or

Education, technical Categorical •

A categorical exclusion is •

While these activities are categorically excluded assistance and Exclusion recommended because no from further environmental scrutiny, training analyses, environmental impacts are opportunities should be seized to promote studies, expected as a result of these types environmental protection and personal safety coordinating of activities.

They fall under as part of implementation.

activities, Regulation 216(22 CFR 216), sub-workshops and paragraphs 2(c)(2) as activities meetings

; that are categorically excluded.

document information

Page 7/59 transfers; programs involving nutrition, health care or population family planning services studies, projects or programs intended to develop the capability of recipient countries organizations to engage in development planning

Potable

Water Negative •

Depending on the quantity and USAID recommends that implementing partners Supply Determination with nature of the water actions, they develop and submit, for review and approval by

Conditions can impact sensitive habitats and the MEO, the AOTR or COTR, and the Regional groundwater. A through analysis Environmental Advisor, a water quality assurance of cumulative impacts of the plan. This plan should provide reasonable program is required. assurance that both GOM and WHO water quality

Small scale pump and housing standards will be met for USAID-funded drinking repairs as well as behavior change water supply facilities, both at the outset and for efforts often have no the foreseeable future and understanding of the environmental impact quantity and quality of the freshwater resource base; this plan shall, at a minimum cover the following as much as possible:

Principles for allocation of the resource among downstream and upstream communities

The incorporation of health concerns into freshwater mana g ement

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The protection of the aquatic environment

Management of demand

The development of community based competencies that would ensure the sustainability of the infrastructure, within appropriate GOM regulatory and legislative frameworks.

Take advantage of the experience of others water supply, sanitation and hygiene related projects

• Assess local behaviors, social factors and cultural beliefs influencing water use, sanitation and hygiene. Among other, Implementing partners should take into consideration aspects related to hand washing, water collection, transport, and storage behavior of all users, including women, infants, children, the elderly and the infirm.

• Assess water leakage rates in existing water schemes.

• Calculate yield and extraction rates in relation to other area water uses and available supply.

This is necessary to avoid depleting the resource or adversely affecting aquatic ecosystems and/or communities down stream/down gradient. These calculations should take into account historic and projected upstream/up-gradient and downstream/down-gradient supply and demand for water. Projects tapping groundwater should also consider the depth of the water table and the characteristic of the groundwater and the hydrology.

• Assess water quality on its chemical, biological

USAID MG HPN /EE Amendments

Page 9/59 and physical quality to determine if water is safe for human consumption; and to establish a baseline data so that any future degradation can be detected. Apart from testing water quality in the program areas, a baseline downstream testing of water quality is also recommended so that the impact of the project in water quality downstream can be detected in the future. At minimum arsenic and fecal coliform tests should be conducted. Any USAID-supported activity engaged in the provision of potable water must adhere to Guidance Cable State 98 108651, which requires arsenic testing. This guideline is packaged in the "Guidelines for Determining the Arsenic Content of Ground Water in USAID- Sponsored Well Programs in Sub-Saharan Africa. The implementing partners must assure that the standards and testing procedures described in this guideline document are followed for potable water supply activities under this program.

• Water Quality standards recommended:

Selected Water Quality Standards for Human Healthl

Arsenic < 0.01 mg/L

Total Coliforms = not detectable in any 100mL sample

Nitrate (as N03-) < 50 mg/L

1 Reference: WHO, Guidelines for Drinking-Water Quality (3rd Edition), 2004. http://www.who.int/water sanitation health/dwg/gdwg3/en/index.html

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Nitrite (as NO2-) < 0.2 mg/L for long-term exposure

These standards may be slightly different from the GOM standards based on the Ministry of Water WATSAN Procedure Manual.

Maintain periodic testing. Periodic testing is the only way to determine if a water supply is or has become contaminated (other than by observing dramatic and sustained increases in water-borne disease)

• Design improvements with an appropriate scale and capacity. Estimate current and projected water quantity and availability based on current water sources and existing uses, baseline measurements on quantity of water available (including seasonal fluctuations), current and historic water use data (household, agricultural, and institutional), population data and forecasts, current and projected demand up and down stream /up and down gradient, and actual water use for similar projects in the past.

• If possible, data on typical water leakage rates in other existing water schemes should be examined.

• Demand projections should take into account the likelihood that the project might attract additional users.

• Minimize downstream/down-gradient effects of intervention, perhaps by establishing some form of communication with downstream parties.

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Exit strategy and Project maintenance: The exit strategy should foresee the community and/or local government ownership of the water supply, sanitation and hygiene projects.

Local Communities, local Authorities, GOM and Private Sector responsibilities should be defined, agreed between both parties and took on by both protagonists. Preparation for this sustainability mechanism should be clearly stated when doing initial assessment, when designing, when implementing, monitoring and evaluating a water supply, sanitation and hygiene projects.

Environmental maintenance by the community and/or local government should be stressed.

Water

Point-Of-Use Negative The POU common disinfection method •

The chlorine contained in NaOCI needs time to (POU) Treatment Determination with is the use of sodium hypochlorite kill infectious organisms and oxidize organic

Conditions (Sur'eau) which kills 99.99% of matter. The rule of thumb is add the proper pathogen germs (viruses, bacteria). dose of chlorine, wait 30 minutes.

Sodium hypochiorite comes in the form •

If the smell/taste of the chlorine is all you find of an aqueous liquid. objectionable, this can be removed by letting the chlorinated water "stand"" and evaporate

The toxic effects of sodium and some chlorine several hours, or aerating the calcium hypochiorite are due water by pouring it back and forth between two primarily to the corrosive containers for a while to liberate some of the properties of hypochiorite. chlorine. So you do not need to filter the water

If you ingest a small amount of unless you want to.

household bleaches (3-6% •

Sodium hypochlorite is one of the most hypochlorite) you may experience commonly used disinfectants, because it gastrointestinal irritation. is inexpensive and easy to manage. It is

If you ingest a more concentrated effective in killing bacteria, but has limited commercial bleach (10% or higher effectiveness against protozoans that form h ochiorite or h ochlorite cysts in water.

Page 12/59 powder you may suffer severe •

If the water is cloudy or filled with large corrosive injuries to the mouth, particles, strain it, using a cloth, before throat, esophagus and stomach treatment. Large particles, if swallowed, may with bleeding, perforation, and be purified only "on the outside."

eventually death. •

Add the chemical to the water and swish it

Permanent scars and narrowing of around to aid in dissolving. Splash some of the the esophagus may occur in water with the chemical onto the lid and the survivors of severe intoxication. threads of the water bottle so that all water (Agency for Toxic Substances and areas are treated.

Disease Registry, CDC, Atlanta) •

The water should sit for at least 30 minutes

It is non combustible under normal after adding the chemical to allow purification conditions but emits toxic fumes of to occur chlorine and sodium oxide when •

In the event of a fire involving sodium heated to decomposition. hypochlorite, use fine water spray and liquid-tight protective clothing with breathing apparatus.

Other disinfection methods include using ozone which acts very rapidly or Ultra Violet light that is almost instantaneous also inactivate pathog ens and used in USAID WASH Pro g rams.

Sanitation facilities Negative •

Depending on the quantity and The Implementing partners shall implement the

(latrines Determination with nature of the sanitation activities, following mitigating measures to the utmost:

construction) Conditions a group of latrines can impact •

Identification of social barriers: Devote sensitive habitats and adequate attention to identifying and groundwater.

A through analysis addressing social barriers to using latrine of cumulative impacts of the •

Evaluate depth to water table including program is required. seasonal fluctuations and groundwater hydrology. The size and composition of the unsaturated zone determine the residence time of effluent from the latrine, which is the key factor in removal and elimination of pathogens.

Pit latrines should not be installed where the water table is shallow or where the com position

Page 13/59 of the overlying deposits makes groundwater or an aquifer vulnerable to contamination.

• Decommissionning: Properly decommission pit latrines. Do not leave pits open. Fill in unused capacity with rocks or soil. Ensure that collected material is adequately treated and not directly applied to fields or otherwise disposed of improperly.

• Hygiene promotion strategy: Develop a hygiene promotion strategy that takes into account the current hygiene behavior (handwashing, latrine use, water collection, transport, and storage) of all users, including women, infants, children, the elderly and the infirm and, as well as any social/cultural religious factors that may hinder changing behavior.

• Design improvements to match demand, user customs and preferences, climate, and abundance of water.

• Test water quality downstream /down gradient from the proposed site before construction of infrastructure to establish a baseline. Testing after completion of project will provide necessary information for mitigation purposes.

Elements to test include fecal coliform, total suspended solids (TSS), biological oxygen demand (BOD) and nutrients. Maintain ongoing testing to monitor for contamination.

• Avoid sensitive areas: Survey for, and avoid, wetlands, estuaries or other ecologically sensitive sites in the project area. Identify nearby areas that contain endangered species and get professional assessment of species' sensitivity to construction at site.

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Consider appropriate natural treatment systems instead of mechanical systems. These tend to be preferable for small-scale activities as they generally cost less, do not require highly skilled labor, and can frequently be manufactured locally. Also, supplies for maintenance and repair are likely to be more readily available. There are many proven natural treatment options. Examples include double-vault batch composting toilets, double-vault batch dry toilets, upflow anaerobic filters2, biogas reactors3, confined-space constructed wetlands, subsurface wetlands, floating aquatic macrophytes, stabilization ponds and ecological sanitation (urine diversion and arborloo systems).

Malaria prevention Negative •

A Supplemental Environmental •

Mission staff and implementing partners should and control Determination with Assessment and Pesticide refer to the approved amended Pesticide

Conditions Evaluation Report and Safe Use Evaluation Report and Safe Use Action Plan Action Plan (PERSUAP) approved (PERSUAP) as well as the approved IEE for the by BEO will guide the IRS. The safe use of LLIN.

IRS program is NOT covered by this IEE.

For insecticide treated nets, conditions will involve the use of reliable brands and adherence to conditions laid out in the IEE in line with the Africa Bureau's Programmatic Environmental Assessment for Insecticide-Treated Materials in USAID Activities in Sub-Saharan Africa.

This includes the collection and disposal of used nets.

IDf&f@Hek4N0*nep]t3 upflow anaerobic filters and biogasPa

(59,ors both require pumping, so they are not truly "natural treatment systems".

MONITORING AND COMPLIANCE CONDITIONS

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 a general condition of approval for the IEE, and their implementation is therefore mandatory.

HPN Team Requirements:

• The HPN Team Leader, in consultation with Mission COTR(s), AOTR(s), activity managers, implementing partners, the Mission Environmental Officer (MEO), the Regional Environmental Advisor (REA), and the Bureau Environmental Officer (BEOs), as appropriate, will actively monitor and evaluate whether environmental consequences arise during implementation and will modify or end activities if they are deemed to be harmful to the environment. In the event that unforeseen environmental impacts are determined or that mitigation and control measures are insufficient, the HPN team will consult promptly with the Regional Environmental Advisor in USAID/Southern Africa.

• The HPN Team Leader will ensure that new activities at either a program element or sub-element level are covered under an amended IEE before implementation occurs.

• The HPN team will provide to the contractors and grantees the IEE conditions and the activities to which they apply.

• Selection of contractors and grantees should include consideration of the offeror's ability to perform the mandatory environmental compliance requirements as set forth herein. The Regional Contracting Officer (RCO) and/or Contracting Officer (CO) shall include required environmental compliance and reporting language into each contract/grant. The HPN team will subsequently ensure that appropriate budget resources, qualified 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.

• The HPN Team Leader, COTR(s), AOTR(s) and activity mangers will undertake regular and timely field visits and consultations with implementing partners to jointly assess the environmental impacts of ongoing activities and associated mitigation and monitoring conditions.

• In addition, and as appropriate, the HPN team may facilitate and/or subsidize the delivery of activity-specific environmental training to the contractors and grantees.

Implementing Partner Requirements:

• Implementing partners will implement the environmental mitigation and monitoring plan while describing how the project will, in particular terms, implement the conditions in the IEE that apply to project activities. This shall include training of contractor staff and sub - partners, when appropriate.

• Implementing partners will undertake regular field visits to monitor and evaluate program activities and to assess their environmental impact.

• Semester reports by implementing partners will include a brief update on mitigation and monitoring measures being implemented and results of environmental monitoring.

• Implementing partners will complete an annual environmental mitigation and monitoring report of activities undertaken unless specified otherwise. This report is to be submitted to the appropriate AOTR, COTR or activity manager by the end of September each year. This reporting requirement should be incorporated into performance monitoring plans and annual work plans. Environmental monitoring information shall then be compiled by the HPN team and submitted to the MEO for incorporation into the annual Performance Plan and Report.

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• Any grants or fund transfers from implementing partners to other organizations (sub-partners) must incorporate provisions stipulating that an annual environmental monitoring report will be completed; and that activities to be undertaken will be within the scope of the environmental determinations and recommendations of this IEE. This includes assurance that any mitigating measures required for those activities be followed.

• The primary responsibility for adherence to this IEE falls principally on USAID's grantees and contractors. USAID's primary role is to monitor implementing partners to ensure that they are in compliance with this IEE.

As required by ADS 204.5.4, USAID /Madagascar HPN Team will "actively monitor ongoing activities for compliance with approved IEE recommendations, and modify or end activities that are not in compliance" and ensure that adequate time and resources are available to bring all activities into compliance with the requirements of this IEE. If additional activities are added to this program and are not described in this document, an amended environmental examination will be prepared.

Upon completion of an environmental management plan by respective implementing partners, the REA and the MEO will develop an Environmental Mitigation & Monitoring Tracking System or checklist to ensure compliance with environmental regulations.

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APPROVAL OF ENVIRONMENTAL ACTION RECOMMENDED FOR HPN IEE (as amended on June 7, 2010):

CLEARANCE:

Mission Director:

Date:

Rudolph Thomas

CONCURRENCE:

Bureau Environmental Officer/GH:

Teresa Bernhard

Officer/AFR:

Brian Hirsh

File No: 33 Madagascar3 Health Services dated on August 8, 2003 and as firstly amended on September 23, 2009

ADDITIONAL CLEARANCES: (Type Name Under Signature Line)

Mission Environmental Officer: /S/ Date: 06/07/2010

USAID/ Madagascar Tiana Razafimahatratra

HPN & FSDA Office Director: /S/ Date: 06/08/2010 USAID/Madagascar Barbara Hughes

Regional Environmental Advisor:

/S/

Date: 06/10/2010 USAID/Southern Africa, South Africa

Camilien J.W. Saint-Cyr

Distribution List:

USAID/Madagascar HPN AOTR and Activity Managers USAID/Madagascar HPN Team Leader USAID/SA Supervisory Regional Acquisitions & Assistance Office Chief, Pretoria USAID/Madagascar PDA Office Chief

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APPROVAL OF ENVIRONMENTAL ACTION RECOMMENDED FOR HPN IEE (as amended on June 7. 2010):

CLEARANCE:

--yam r ^^ 1, D Mission Director:

Date: cbl/^

Rudolp Thomas

Teresa Bernhard

CONCURRENCE:

Officer/GH : Date:

Officer/AFR:

Brian Hirsh

File No: 33 Madagascar3 Health Services dated on August 8, 2003 qnd as amended on September 23, 2009

ADDITIONAL CLEARANCES: (Type Name Under Signature Line)

Mission Environmental Officer:

USAID/Madagascar

Tiana Razafimahatratra

HPN & FSDA Office Director: Date: c o /IO USAID/Madagascar arbara Hughes ^.1

Regional Environmental Advisor:

USAID/Southern Africa, South Africa

Date: 0.6 14 MI 0

Distribution List:

USAID/Madagascar HPN AOTR and Activity Managers USAID/Madagascar HPN Team Leader USAID/SA Supervisory Regional Acquisitions & Assistance Office Chief, Pretoria USAID/Madagascar PDA Office Chief

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INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM /ACTIVITY DATA:

Program /Activity Number: 687-005

Country/Region:

Madagascar, Southern Africa

Objective:

Investing in People

Program Area:

3.1 Health

Program Elements:

3.1.1 HIV/AIDS, 3.1.3 Malaria, 3.1.6 Maternal and Child

Health, 3.1.7 Family Planning and Reproductive Health, and

3.1.8 Water Supply and Sanitation

Program /Activity Title:

Use of Selected Health Services and Products Increased and Practices Improved

1.0 BACKGROUND AND ACTIVITY DESCRIPTION

1.1 Purpose and Scope of this IEE

USAID/Madagascar's Core Health Program: "Use of Selected Health Services and Products Increased and Practices Improved" was granted a new five-year follow-on program from October 2008 to September 2013. Basically, the follow-on program has the same activities as the previous five years and is complemented with two new ones: Water Supply and Sanitation and Diarrhea Treatment. This umbrella IEE is an amendment of the Core USAID/Madagascar' Health Program IEE. Its purpose is to ensure that environmental consequences of the proposed activities are recognized and considered in their design, implementation and management and mitigated correctly. The findings of this IEE amendment will also assist Implementing Partners (IPs) in adopting environmental best practices in their activity designs.

Specifically, this IEE amendment will (1) cover both follow on and new activities under the USAID/Madagascar's Health, Population and Nutrition (HPN) program; (2) adapt the "Foreign Assistance" framework with the USAID/Madagascar HPN Program IEE; (3) provide threshold determinations of environmental impact and conditions for mitigation, and (4) provide Environmental Compliance guidance to small/sub grants within some HPN program activities.

The HPN program activities contribute to Government of Madagascar (GOM) objectives. It includes five Program Elements: 3.1.1 HIV/AIDS, 3.1.3 Malaria, 3.1.6 Maternal and Child health, 3.1.7 Family Planning and Reproductive Health, and 3.1.8 Water Supply and Sanitation. This IEE replaces the Strategic Objective No5 IEE and is a starting point for new or continuing activities to be covered under the amended Strategic Objective Agreement (SOAG), and is intended to support the Mission Strategic Plan goal to "Expand and Improve Health Care Services". The HPN Program, broken down to Program and Sub-Elements is summarized below. Expected results include:

• Demand for Selected Health Services and Products Increased;

• Availability of Selected Services and Products Increased;

• Quality of Selected Services Improved; and

• Institutional Capacity to Implement and Evaluate Health Programs Improved.

As requested by the BEO/GH, this IEE proceeded to a more comprehensive evaluation of cumulative and long term impacts to the environment including sensitive habitats and socio economics to ensure that HPN program activities remain environmentally sound and socio-economically viable.

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1.2 Background

Madagascar faces many challenges in reaching its health goals. Key barriers include an inadequate level of overall financing, low or uneven utilization of health services, uneven distribution of health personnel, disruptions in the availability of drug and medical supplies in health facilities, and weaknesses in the internal administration of the health system, especially with respect to budget execution. Taken together, health problems have substantial implications for the country's economic and environmental well being. Some of the major health problems are family planning, childhood and maternal health, malnutrition, malaria, STI/HIV/AIDS, and potable water. The Government of Madagascar (GOM) hopes to achieve the following objectives by 2012 from baseline estimates in 2004/2005: a reduction of the infant mortality rate from 94/1,000 to 47/1,000 and neonatal mortality rate from 32/1,000 to 17/1,000; an increase in the percentage of children receiving supplementary micronutrients from 80% to 100%; an increase in the percentage of one year olds immunized against measles from 84% to 100%; a reduction in the maternal mortality ratio from 469/100,000 to 273/100,000; an increase in contraceptive prevalence rate from 18% to 30%; and a reduction of HIV prevalence among pregnant women from 0.95% to 0.8%. USAID aligns its activities in order to contribute to improvements in health status and a reduction in population growth, both of which are necessary to maintain a healthy population who can productively contribute to achieving rapid economic growth, a competitive niche in the global economy, and a protected environment. USAID provides support in different fields of activities including HIV/AIDS, malaria, maternal and child health (MCH), family planning / reproductive health (FP/RH), and water supply and sanitation, working with MOH, GOM partners, nongovernmental bodies, the private sector, and communities.

1.3 Description of Activities and Geographic Focus(es)

Program Element 3.1.1 HIV/AIDS

3.1.1.02 Abstinence/Be Faithful

3.1.1.05 Condoms and Other Prevention Activities

3.1.1.09 Counseling and Testing

3.3.3.13 Other/Policy Analysis and System Strengthening

Madagascar's HIV prevalence remains below 1%. However, it has one of the highest sexually transmitted infections (STI) rates in the world. Activities include promotion of abstinence and fidelity; prevention of HIV transmission including promotion of condoms and sexually transmitted infection (STI) management; and counseling and testing for youth. HPN program builds on innovative behavior change interventions, engaging the private sector and civil society, and enhancing capacity of communications and private medical personnel to deliver quality health messages and services. The emphasis is on prevention, reaching the most vulnerable groups-such as youth, female sex workers, men having sex with men, and mobile men- with targeted behavior change communication interventions. Programs also work to reduce STI prevalence by ensuring availability of quality services and products while working closely with partners to expand successful models in STI prevention, treatment, and behavior change for youth such as the innovative youth prevention program with scouts, sports and school clubs. The Red Card campaign will continue to empower young girls to say "no" to risky sexual situations. Along with other partners, activities support distribution and access to STI pre-packaged treatment kits, educational materials, and a franchised network of youth-friendly private sector service providers (Top Reseau). Supports include also the decentralization of the HIV/AIDS response at the regional level by providing technical assistance to the regional AIDS committee and local associations, and HIV surveillance and monitoring and evaluation in collaboration with World Health Organization, World Bank, Centers for Disease Control, and UNAIDS. It is expected that more Malagasy youth will practice abstinence, millions of people are reached with appropriate behavior change messages and interventions, and hundreds of thousands of people will receive high-quality STI and HIV prevention and care services. Implementing partners are formed by Ministry of Health and Family Planning, at grassroots level (from SSD to central level), Private

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Program Element 3.1.3 Malaria

3.1.3.1 Treatment with Artemisinin-based Combination Therapies (ACT)

3.1.3.2 Insecticide-Treated Nets (ITNs) to prevent Malaria

3.1.3.4 Intermittent Preventive Treatment (IPT) of pregnant women

3.1.3.9 Host Country Strategic Information Capacity

Malaria is a key public health concern in Madagascar; it is ranked as a leading cause of under-five mortality in the country and is currently responsible for 11 percent of all outpatient visits and 20 percent of hospital admissions in children under five years of age (2007 Ministry of Health service statistics). Malaria epidemiology varies from stable transmission on the east and west coasts to seasonal, unstable transmission in the central highlands and the south.

The President's Malaria Initiative (PMI) Strategy and Malaria Operational Plan for Madagascar are based on an assessment that engaged and included the perspectives of all national and international stakeholders. PMI supports the national malaria control strategy and will contribute to the Malagasy government's objective to halve malaria mortality by 2012 while focusing on the following activities: community mobilization; improved access and use of insecticide treated nets (ITNs); indoor residual spraying in unstable zones; access to and use of Intermittent Preventive Treatment (IPT) of pregnant women with sulfadoxin pyrimethamin (SP); case management with artemisinin-based combination therapy (ACT); drug quality assurance, and strengthening of the national malaria control program's capacity in surveillance, laboratory methods, commodity management, and monitoring and evaluation through support to Host Country Strategic Information Capacity. Expected results include procurement and distribution of Long Lasting Insecticide Nets (LLINs) as part of a nationwide mass distribution campaign; expansion of use of IRS to prevent malaria, prevention of malaria in pregnancy with sulfadoxin pyrimethamin (SP), expansion of home-based management of malaria, improved performance of community health workers to deliver a package of child health interventions, trained staff and improved access to health services and products at health facilities. Implementing partners include RBM Parnership, Santenet, Red Cross, UNICEF, MCDI, Voahary Salama, etc. The zones of coverage are focused on the south, east, west and northern regions of the country in which malaria is endemic.

Program Element 3.1.6 Maternal and Child Health

3.1.6.01 Birth Preparedness and Maternity Services (including prenatal and post-partum care)

3.1.6.02 Treatment of Obstetric Complications and Disabilities

3.1.6.03 Newborn Care and Treatment

3.1.6.04 Other Immunizations including Polio

3.1.6.06 Maternal and Young Child Nutrition including Micronutrients

3.1.6.07 Treatment of Child Illness

3.1.6.08 Household Level Water, Sanitation, Hygiene, and Environment

3.1.6.11 Host Country Strategic Information Capacity

Diarrheal disease remains the primary cause of mortality and morbidity among children under five; however, acute respiratory infections and newborn deaths are also critical contributors.

Activities addresses infectious diseases, malnutrition, Integrated Management of Childhood Illness (IMCI), and hygiene and sanitation practices by concentrating on service delivery in health facilities, reinforcement of essential nutrition actions, and emphasis of community based health outreach. In addition, marketed under the brand name Sur'Eau, the water purifier has been introduced and distributed nationwide. Maternal and Child Health (MCH) activities help also expand assistance for maternal and newborn care, a high priority issue in the country. Supports include Treatment of Obstetric Complications and Disabilities; Birth Preparedness and Maternity Services including prenatal and post-partum care; Newborn Care and Treatment; Other Immunizations including Polio; Maternal and Young Child Nutrition including Micronutrients;

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Treatment of Child Illness; and Host Country Strategic Information Capacity. Capacity building in MCH planning, service delivery and monitoring to all levels of the health system will be provided.

These efforts will contribute to improving human capacity for a productive life, sustainable livelihoods, and economic growth. Expected results are to continue to lower the maternal, child, and infant mortality rates in Madagascar through among others immunization and preventive treatment of malaria in pregnant women, training of health workers for safe delivery, expanding the availability of emergency obstetric care, and enhanced neonatal care services. Implementing partners are USAID/Santenet2, PSI, Care, CRS, MCDI, WCS, etc; they are working at national level.

Program Element 3.1.7 Family Planning and Reproductive Health

3.1.7.1 Service Delivery

3.1.7.2 Communication

3.1.7.3 Policy Analysis and System Strengthening

3.1.7.5 Host Country Strategic Information Capacity

Activities include supports to Service Delivery, Communication, Policy Analysis and System Strengthening, and Host Country Strategic Information Capacity. Supports are provided to the MOH, nongovernmental organizations (NGOs), and the private sector to increase demand for and access to quality FP services and products such as oral and injectable contraceptives as well as condoms, oral contraceptives, intrauterine devices, and Standard Days Method (SMD) cycle beads for social marketing. Post-partum FP will be reintroduced among the best practices used at the community level. Capacity building is provided to the MOH to manage its logistics and delivery systems to control stock outs of health commodities through the National Medical Stores. Activities focus also on support to scaling-up best practices, including pregnancy checklists, systematic screening, and community based distribution of Depo-Provera, and an increased focus on long-term FP methods. Social marketing of FP/RH products will be expanded deeper into rural communities. A comprehensive behavior change communication program will support these efforts. Program will also strengthen NGO capacity, and will continue integrated health, population, and environment interventions in remote sites. It is expected that increased availability and enhanced quality of services and commodities at the community level will further increase use of FP. Implementing partners include USAID/Santenet2, PSI, FHI, Care, MCDI, WCS, Voahary Salama, etc. and work at national level.

Program Element 3.1.8 Water Supply and Sanitation

3.1.8.1 Safe Water Access

3.1.8.2 Basic Sanitation

3.1.8.3 Water and Sanitation Policy and Governance

3.1.8.4 Sustainable Financing for Water and Sanitation Services

3.1.8.7 Host Country Strategic Information Capacity

Diarrheal disease resulting from contaminated water supply, poor hygiene and sanitation is one of the primary causes of mortality and morbidity among children under five. More than 65% of the population does not have access to safe drinking water or sanitation. Access to improved water supply alone is insufficient to improve health without accompanying behavior changes.