Attachment_5._Health_IEE_2012-17..pdf

INITIAL ENVIRONMENTAL EXAMINATION

AND

CATEGORICAL EXCLUSION

PROGRAM/ACTIVITY DATA:

Program/Activity Number: 695-A11 Country/Region: Burundi/East Africa/Limited Presence Countries

Functional Objective: 3 – Investing in People Program Area: 3.1-Health Program Elements: 3.1.1-HIV/AIDS 3.1.3-Malaria 3.1.6-Maternal Child Health 3.1.7-Family Planning/Reproductive Health

Program/Activity Title: Health Funding Begin: FY 2012 Funding End: FY 2015 LOP Amount: $140,000,000

IEE Prepared By: David Kinyua USAID/EA Regional Environmental Adviser

Current Date: July 11, 2012

IEE Amendment (Y/N): N__

Original IEE:___N/A

IEE Expiration Date: July 11, 2017

ENVIRONMENTAL ACTION RECOMMENDED:

Categorical Exclusion: X Negative Determination: X .

Positive Determination: Deferral ____

ADDITIONAL ELEMENTS:

CONDITIONS X PVO/NGO: X .

SUMMARY OF FINDINGS:

The purpose of this Initial Environmental Examination (IEE) is to provide threshold determination for the new activities of USAID/Health programs in accordance with the requirements of Regulation 22 CFR 216 (Reg. 216). This IEE will assist in ensuring environmental compliance, and also permit the implementa-tion of the proposed activities in accordance with USAID Environmental Policy and Procedures (22 CFR Part 216).

Environmental Determinations The following Environmental Determinations are recommended:

1. A Categorical Exclusion from environmental examination is recommended for activities not involving biophysical interventions in this program

a) HIV/AIDS Enhancing behavior change communications: promoting correct and consistent condom use; support-ing activities against gender discrimination and GBV through income generating activities; providing nutritional support to HIV positive mothers during the weaning period; and supporting performance-based financing.

b) MCH Building the capacity of national authorities and provinces for data; Increasing the skills for maternal and child health; antenatal care and birth preparedness, emergency obstetric care, integrated man-agement of childhood illnesses, routine immunizations, growth monitoring, and young child nutrition;

Supporting BCC; and supporting the decentralization process through performance-based financing approach.

c) FP/RH Improving the reproductive services; supporting BCC activities; increasing counseling and family planning services for women living with HIV; and supporting health coordination at the national, provincial, and district levels.

d) Malaria Improving the national entomological surveillance capacity; strengthening the capacity; strengthening anti-malaria drug quality monitoring and surveillance; supporting the in-country supply; developing a national malaria control

Pursuant to:

22 CFR 216.2(c)(2)(i), for activities involving education, technical assistance or training programs;

22 CFR 216.2(c)(2)(iii), for activities involving analyses, studies, academic or research workshops and meetings;

22 CFR 216.2(c)(2)(v), for activities involving document and information transfers; and 22 CFR 216.2(c)(2)(viii), for programs involving nutrition, health care, or family planning services except to the extent designed to include activities directly affecting the environment (such as con-struction of facilities, water supply systems, and waste water treatment).

2 Negative Determinations:

A Negative Determination with Conditions is recommended pursuant to 22 CFR 216.3(a)(2)(iii) for the following activities:

2.1 Generation, storage, handling and disposal of hazardous and highly hazardous medical waste

Conditions:

For all USAID-supported activities entailing service delivery, including blood testing and laboratory support, USAID/Burundi Health Team will work with its implementing partners to assure, to a rea-sonable extent possible, that the medical facilities and operations involved have adequate procedures and capacities in place to properly handle, label, treat, store, transport and properly dispose of blood, sharps and other medical waste. Health Team A/CORs and activity managers will ensure implement-ing partners complete on an annual basis the “Healthcare Waste Management Minimum Program Checklist and Action Plan” (see Annex 1 of this IEE) for all facilities where implementing partners are directly providing services.

2.2 procurement, storage, management and disposal of public health commodities:

Conditions:

Consignees for all pharmaceutical drugs procured under this funding will be advised to store products according to the information provided on the manufacturer’s Materials Safety Data Sheet (MSDS).

These are supplied by the manufacturer, and can also be found on the internet by using active ingredi-ents and MSDS as search terms. If disposal of these pharmaceutical drugs is required, due to expira-tion date or other reasons, the consignee will be advised that the preferred method of disposal is to return the product(s) to the manufacturer. If this is not possible (e.g., if the expired or spoiled pharma-ceuticals are considered hazardous and, if transferred across frontiers, become regulated and subject to the Basel Convention on the trans-frontier shipment of hazardous wastes) then follow the guide-lines in the WHO document Guidelines for Safe Disposal of Unwanted Pharmaceuticals During and After Emergencies, found at www.who.int/water_sanitation_health/medicalwaste/unwantpharm.pdf.

At the request of the Mission, subject to available funding, implementing partners will make reasona-ble attempts to facilitate the disposal of expired drugs under this activity to mitigate the impact of medical waste.

2.3 Construction of Small Scale structures

Conditions:

For the rehabilitation of existing facilities, and for construction of facilities in which the total surface area disturbed is less than 10,000 square feet, and no protected or other sensitive environmental areas could be affected, the condition is that these activities shall be conducted following principles for environmentally sound construction, as provided in the Small Scale Construction chapter of the USAID Environmental Guidelines for Small-Scale Activities in Africa.

2.4 Long Lasting Insecticide Treated Nets

Conditions:

As described in the PEA ITM, The World Health Organization-recommended brands of LLITNs rather than nets requiring re-treatment are the most effective risk mitigation measure available. So long as the Health Team restricts its product choice to these LLITNs, further mitigation measures are not needed. If a need for net treatment or re-treatment arises under this funding, USAID/Burundi Health Team will draft and gain approval for a “Pesticide Evaluation Report and Safer Use Action Plan” (PERSUAP) for the pesticides proposed for the re-treatment program. Except for LLITNs, as outlined above, this examination does not cover pesticides, including their procurement, use, transport, storage or disposal. Support for any other pesticide-related activity considered under HEALTH, for example indoor residual spraying, or the use of pesticides in construction or agriculture, will necessitate the preparation of a Pesticide Evaluation Report and Safer Use Action Plan (PERSUAP) to address what pesticides may be used and under what conditions (training, safety equipment, etc.) in accordance with AFR Bureau guidance and fulfilling all analytical elements required by 22CFR216.3(b), USAID's Pesticide Procedures.

2.5 Sub grants and sub awards

Any grants or other monetary transfers of USAID funds (e.g., sub-grants) to support this program’s activities must incorporate provisions that the activities to be undertaken will comply with the envi-ronmental determinations and recommendations of this IEE. This includes assurance that the activi-ties conducted with USAID funds fit within those described in the approved IEE or IEE amendment and that any mitigating measures required for those activities be followed.

3. Pesticides: This IEE amendment does not cover procurement, use, transport, storage or disposal of pesticides or other toxic materials, which would require an amended IEE, pursuant to 22 CFR 216.3(b), USAID’s Pesticide Procedures. Likewise, any activities implicating the testing and use of genetically-modified organisms (GMOs) or life-modified organisms (LMOs) shall be subject to review under the Agency’s Biosafety procedures.

4. Monitoring and Evaluation:

The USAID-funded implementing partners will provide to USAID/Burundi team, as specified pursuant to the portfolio review and any conditions in their grants, sub grants or agreements, requested documentation, including, as applicable to activities, documents that demonstrate conformance with the environmental regulations, physical planning standards or building codes and conditions, as detennined under this IEE.

• Periodic visits of the US/\ID/Bunmdi Team Managers or DO Team leader, with, if possible MEO, REA or other spcdalists as appropriate, will be encouraged to ensure environmentally sound implementation, mitigation and monitoring of activities.

Per ADS ::?04.S.4, USAID/Bunindi Health Team "shall actively monitor ongoing activities for compliance and modify or end activit ies that arc not in compliance" and ensure that adequate time and resources are available to bring all activities into compliance with the requ irements of this lEE amendment.

APPROVAL OF THF. R ECOMMENDED ENV,JRONMENTAL ACTION:

CLEARANCE:

Regional Mission Director:

Jeffrey · ley

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Brian Hirsch

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ADDITIONAL CLEARANCES:

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LPC Office Director: ~~A W\ ~ ,All\~

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Burundi Country Representative:

J mes Anderson \ \. ~-

)) \ \ 1 ' Regional Environmental Advisor (USA!DlEA);.~--t''' <.:---~,~-

David Kinyua (j

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INITIAL ENVIRONMENTAL EXAMINATION

AND

CATEGORICAL EXCLUSION

Program areas:

Functional Objective: 3 – Investing in People Program Area: 3.1-Health Program Elements: 3.1.1-HIV/AIDS 3.1.3-Malaria 3.1.6-Maternal Child Health 3.1.7-Family Planning/Reproductive Health

Country/Region: USAID/East Africa/Limited Presence Countries, Burundi

1.0 PURPOSE AND SCOPE OF THIS INITIAL ENVIRONMENTAL EXAMINATION (IEE)

1.1 Purpose and Scope of this Initial Environmental Examination (IEE) The purpose of this Initial Environmental Examination (IEE) is to provide threshold determination for the new activities of USAID/Health programs in accordance with the requirements of Regulation 22 CFR 216 (Reg. 216). This IEE will assist in ensuring environmental compliance, and also permit the implementa-tion of the proposed activities in accordance with USAID Environmental Policy and Procedures (22 CFR Part 216).

1.2 Background

The disease burden in Burundi is dominated by infectious and communicable diseases, primarily diarrhea, malaria, and HIV/AIDS. Acute respiratory tract infections, malaria, and waterborne diseases, particularly diarrhea, remain the main causes of death in children under five years of age. In adults, AIDS is among the leading causes of death—although it is likely to be underreported given the high levels of stigma. In addition, chronic and non-communicable diseases, such as malnutrition, high blood pressure, diabetes, and mental illness, also factor into the overall picture of morbidity and mortality in Burundi.

The Global Health Initiative (GHI) strategy for Burundi, designed to run from 2011 to 2015, is based in large part on the Government of Burundi’s (GOB) National Health Development Plan that covers the same time period. The USAID program aims to support the GOB to increase the quality and utilization of services for maternal and child health (MCH), family planning and reproductive health (FP/RH), HIV/AIDS, and malaria while also working to strengthen the national health system. The interventions will build on successes achieved by USAID’s previous work in these areas and high-level indicators of success will be decreases in: (1) maternal and under-five mortality; (2) the number of new HIV infections in the general population; and (3) malaria morbidity.

Funding for MCH, malaria, FP/RH, and a portion of the HIV/AIDS work will come from the GHP- USAID account. The remainder of the HIV/AIDS funding will come from the GHP-State account. The expected budget level for this sector is estimated to be approximately $160 million over five years, of which $25 million is non-initiative funding. This program will be managed primarily through Investing in People (IIP) Assistance Agreement as well as some targeted field support activities.

1.3 Description of Activities

The proposed interventions will cover four health-related program elements, which are HIV/AIDS, malaria, maternal and child health, and family planning/reproductive health. They will contribute to the implementation of the Burundi’s PRSP and NHDP.

1.3.1 Human Immunodeficiency Virus/ Acquired immunodeficiency Syndrome (HIV/AIDS) The overarching goal of the HIV/AIDS program in Burundi is to strengthen the capacity of the Burundian government, civil society, and the private sector to plan, deliver, monitor, and evaluate high-quality, sustainable HIV/AIDS prevention, care, and treatment services. To build civil society’s capacity, the USG will support sub-grants and technical assistance to local organizations to build their organizational, financial, programmatic, and technical competence to deliver high-quality services and enable them to “graduate” to USG prime-partner status over the coming years.

More specifically, the HIV/AIDS program will focus on the following activities designed to improve the policy environment, service delivery, and systems development. The USG program will attempt to support 100% of health facilities in the four current focus provinces (Kayanza, Muyinga, Kirundo, and Karuzi) and quickly increase the Prevention of Mother To Child Transmission (PMTCT) coverage to four additional provinces (Ngozi, Gitega, Bujumbura Rural, and Bujumbura Mairie) with the intent to scale up to nationwide PMTCT coverage in the near future:

Funding local organizations to provide home-based care and support for People Living with HIV/AIDS (PLWHA) and Orphans and Vulnerable Children (OVC);

Reinforcing the laboratory system by supplying reference laboratories with equipment and rea-gents for biological follow-up including hematology and biochemistry for HIV+ pregnant women and people under Anti-Retroviral Treatment (ART) and through training and supervision of lab technicians;

Enhancing behavior change communications that addresses underlying risk factors for HIV such as Gender-Based Violence (GBV), alcohol abuse, social, and cultural norms;

Promoting correct and consistent condom use;

Supporting activities against gender discrimination and GBV through income generating activi-ties;

Procuring test kits for 80% of pregnant women and 6% of the general population in the focus provinces;

Improving access to voluntary testing and counseling as well as provider-initiated testing and counseling (PITC);

Increasing access to PMTCT services;

Supporting a modest male circumcision program;

Reinforcing the national supply chain;

Expanding interventions relating to Post-Exposure Prophylaxis (PEP) in cases of rape, occupa-tional exposure, and for the prevention of MTCT;

Providing nutritional support to HIV positive mothers during the weaning period; and Supporting performance-based financing.

1.3.2 Maternal Child Health (MCH)

The proposed activities will be implemented in Kayanza and Muyinga provinces. If funding were to increase in the coming years, activities could be expanded to additional provinces. The program will build on prior USAID investments in health center and community-level provision of MCH services, complement the work of the PEPFAR program in Burundi, work closely with the other USG and other donor programs and initiatives, and will focus on the following principal objectives:

Building the capacity of national authorities and those in targeted provinces and health districts to collect, analyze, disseminate, and act on health information data;

Increasing the skills of provincial and local health care providers to address key challenges to maternal and child health;

Providing an improved primary health care package of interventions that includes antenatal care and birth preparedness, emergency obstetric care, integrated management of childhood illnesses, routine immunizations, growth monitoring, and young child nutrition;

Supporting BCC activities to identify, prevent, and address key maternal and child health risks;

and

Supporting the decentralization process through the establishment of the performance-based financing approach.

1.3.3 Family Planning and Reproductive Health (FP/RH)

USG assistance will build on the efforts already undertaken through the MCH program and the USAID/East Africa Flexible Family Planning program and will support integration with the PEPFAR program in line with GHI principles. The program will focus on:

Procuring select commodities to fill the gaps, in close consultation with the National Reproduc-tive Health Program;

Supporting community-based distribution of contraceptives;

Improving the provision of FP/RH services including youth-friendly reproductive health services in the eight provinces planned to have PMTCT activities under PEPFAR;

Supporting the creation of satellite FP centers to compliment faith-based health centers that do not provide modern contraceptive methods;

Supporting BCC activities including male involvement, consistent and correct condom use, and promotion of long acting methods such as implants and Inter-Uterine Devices (IUD);

Increasing counseling and family planning services for women living with HIV; and Supporting health coordination at the national, provincial, and district levels.

1.3.4 Malaria

In order to support the GOB in the fight against malaria, USG efforts will support the following activities that are all nationwide except where otherwise noted:

Procuring Long-Lasting Insecticidal Treated Nets (LLINs) to achieve and maintain universal coverage throughout the country distributed through periodic mass campaigns and continuous channels including Antenatal Care (ANC), immunization clinics, and other innovative means;

Improving the national entomological surveillance capacity;

Supporting confirmed diagnosis of malaria at facility and community level before treatment by procuring rapid diagnostic tests, supporting high quality microscopy, and strengthening provider adherence to malaria diagnostic results;

Procuring anti-malarial drugs to ensure adequate stocks of life-saving medication at the national level for the public sector facilities;

Strengthening the capacity at all levels of the health system to a) provide correct treatment at facilities, b) monitor and supervise treatment being provided at those facilities; c) improve the quality control and assurance of the malaria case management system;

Strengthening anti-malaria drug quality monitoring and surveillance by improving the pharma-covigilance system including documenting and monitoring of adverse reactions to malaria treat-ments;

Supporting the in-country supply chain logistics and pharmaceutical management in collaboration with the national supply chain system at the national, district, and facility level to minimize Ar-temisine Combination Therapy (ACT) stock outs at the facility level;

Developing a national malaria control monitoring and evaluation plan and supporting its imple-mentation;

Supporting the continuation and scale up of a Community-Case Management Of Malaria (CCM) program (not expected to be supported nationally by USAID, given limitation of funds). The USAID program will conduct an internal performance evaluation in early FY 2013 of the CCM pilot activity that will inform GOB plans to scale up the program.

2.0 SUMMARY OF COUNTRY ENVIRONMENTAL INFORMATION

2.1 Overview of Environmental Issues

Burundi is a small, landlocked country that has been severely damaged by a protracted civil war that began in 1993 and tapered to a close sometime between the 2000 Arusha Accords and a 2006 ceasefire between the GOB and a hold-out opposition group known as the Force Nationale de Liberation (FNL).

Despite the recent years of peace, Burundi remains one of the poorest countries in the world and ranked 185 out of 187 countries on the 2011 U.N. Human Development Index. Burundi is also the poorest of the EAC partner states with a per capita gross national income of $140, compared to $620 among the other member countries. According to the U.N. State of World Population 2011 report, 81 percent of Burundi’s population is estimated to be living on less than $1.25 per day.

In 2010, USAID/Burundi completed a comprehensive mandatory FAA 118/119 analysis in the form of Environmental Threats and Opportunities Analysis (ETOA). The ETOA provides very informative background on the major environmental issues, trends and opportunities. Some of the issues are highlighted in this section. Burundi straddles the Congo and Nile divide in the Great Rift Valley and is bordered by Rwanda, Tanzania, and the Democratic Republic of Congo. Fundamental to Burundi’s environmental threats is one of the highest population densities in Africa: Burundi has a density of over 300 inhabitants per square kilometer in some areas.

Although most of its natural habitat has been converted or destroyed, Burundi still retains some key ecosystems in the Rift Valley that are essential to conserve. The Kibira National Park is one of the last remaining intact stretches of Afro-montane forests in the region; the Ruvubu Park in the east is a unique region of woodlands and savannah and related fauna; the Northern Aquatic Landscape (Lacs du Nord) is an important bird habitat for migrating species; and Lake Tanganyika, as one of the largest lakes in the world, presents food for thought in all sectors. Burundi is home to thousands of bird species, charismatic chimpanzee populations, roaming buffalo, the popular Sangala, colorful cichlid fishes, crocodiles, hippos, and many other animal species. Due primarily to high population pressure on natural habitats and biological resources, there has been a gradual disappearance of much of the original natural forest ecosystems with associated impacts on the biodiversity, namely extirpation of several large mammals (e.g., elephants Loxodonta africana and gorillas Gorilla gorilla).

The high population growth (2.7% per year) continues to lead to high pressure on natural resources. With traditional subsistence practice being the predominant mode of production, it is difficult to attain self sufficiency in producing enough food for a household, much less generate income. Agriculture and natural resources (including forestry, fisheries and livestock) provide the mainstay of the Burundian economy, accounting for over 50% of the GDP, about 90% of the export of goods, and support for about 90% of the labor force. Most of these laborers are subsistence farmers, and 90% of these farmers are women.

Demand for fuelwood and construction wood has caused a high rate of deforestation such that natural forest cover is down to 3.5% of land area, from an original forest cover of 46.3%. Only 5% of the land area is in a national protected area system, which protects only 18% of the tropical forest cover remain-ing. Deforestation has also forced farmers to use straw and other crop residues for fuel, thereby further damaging soil fertility. These factors have led to a disastrous shortfall in food production, with two-thirds of the population unable to meet even the minimum food energy requirement of 2,100 calories per person per day. Access to clean water is also a problem in rural areas, where only about 49% of the population are considered to have reasonable access. Women in particular bear a large part of the inconveniences imposed by environmental constraints (lack of wood or other fuel sources, water supply). The fact that women have few opportunities for involvement in decision-making tends to perpetuate this situation.

Environmental stresses are recognized frequently to be a contributing factor to the conflicts and humanitarian emergencies in Africa. The widespread depletion of soil fertility, inadequate protection of environmental quality and inequitable distribution of economic benefits are all important sources of environmental stress in Africa. There appears to be a trend toward increasing urbanization accentuated by recent droughts and the insecurity associated with the civil war, including in the IDP and resettlement camps themselves. Food security and health conditions have also been severely impacted, and prospects for sustainable growth have been undermined. Not least is the role of the inequitable distribution of the natural resources including land and means of production. Burundi’s main export is coffee which is considered strategic. But, while it is grown by the majority Hutus, processing and marketing is controlled by a small powerful Tutsi elite; this arrangement has been a source of conflict.

Burundi has significant mineral resources, though these are currently largely unexploited. In addition to various precious metals and minerals, phosphate and calcareous deposits exist in Burundi that could be extracted and put to use to improve the fertility of the acid soils. A large rift valley lake, Lake Tanganyi-ka, provides many options for sustainable economic development around trade and fisheries. Burundi’s aquatic resources also lend themselves to aquaculture development. Ecotourism has much potential in Burundi as well, especially around the national conservation areas including Kibira National Park, Ruvubu, and Lake Tanganyika.

2.2 Social Economic Issues

Demographic and Health Survey (DHS) data show that the total fertility rate is 6.4 children per woman while the national contraceptive prevalence rate (CPR) is estimated at only 18 percent for modern methods.

Some health indicators significantly improved when DHS data was collected in 2010 compared to levels from a 2005 multi-indicator cluster survey. Examples of these successes include: (1) the percent of children 12-23 months who have received all recommended vaccines rose from 45 to 83%; (2) the proportion of pregnant women attending antenatal care services for at least one visit was 92% and has now reached 99%; (3) the percentage of births taking place in a health center is up from 29 to 60%; and

(4) the CPR increased from 8 to 18%. It should be noted that the 2010 DHS was the first in Burundi since 1987.

Although some improvements have been made in recent years, the overall picture that the health indicators paint for Burundi continues to be one of deep concern. Burundi has an estimated maternal mortality rate of 886 per 100,000 live births and an under-five mortality rate of 96 per 1,000 live births.

The DHS revealed that the chronic malnutrition rate was 58% and the acute malnutrition rate was 6%.

HIV prevalence among the general population is 2.9% according a national HIV survey conducted in 2008. A recent report on the evolution of the Millennium Development Goals (MDGs) showed that Burundi’s performance has been considerably weaker than those of the rest of Sub-Saharan Africa and is not likely to achieve the targets set for reducing infant mortality, maternal mortality, and HIV incidence by 2015 unless there is a dramatic improvement in service delivery.

2.3 Opportunities for Intervention

Given the share of agriculture in employment and land use, addressing the causes of low agricultural productivity is critical to stimulating sustainable economic growth and improving national food security.

The GOB’s 2008 analysis of constraints indicated that low agricultural productivity of food and cash crops is the greatest obstacle to economic growth after low domestic investment. Regarding food crops, there is a need to address inadequate incentives for farmers to introduce modern inputs, poor physical infrastructure and extension services to modernize the sector, weak farmer cooperatives and marketing organizations, and across-the-board sector distortions created by government intervention. With regard to cash crops, the liberalization of agricultural prices and a diminished role for the public sector in the production and commercialization of coffee and tea, and especially the ongoing privatizations of coffee washing stations, are significant steps in the right direction. However, the speed of implementation of these programs needs to be accelerated to achieve greater impact on income growth, food security, and household nutritional status.

Diversification away from subsistence agriculture is particularly important. Given the nutritional profile, population growth trends, and the sheer scarcity of land, Burundi cannot realize adequate and sustainable economic growth within revenues currently generated per unit of land. Although the transformation away from subsistence agriculture will not be achieved for many years, the move should begin now based on a detailed analysis of potential products and markets.

The 2011 World Bank “Burundi Country Economic Memorandum” identifies three key interventions to support the national poverty reduction strategy within the agriculture sector as follows: 1) continue to facilitate diversification and the increased contribution of other products, such as horticulture and fishing;

2) increase the availability of cargo space to export fresh produce; and 3) improve compliance with sanitary and phytosanitary standards (SPS).

The following areas are well within the manageable interest of USAID programs:

Land-related policy and institutional reform processes should be seen through to their formal adoption and supported towards their effective implementation;

Creation of Wetlands Code for sustainable intensification Introduce Climate public awareness on watershed management, promoting non-wood energy sources, and collection, analysis, and dissemination of agro-climate early warningsduction of community-based and participatory resource management practices via enterprise-based, social self-help and other types of associations Promote linkages with the regional natural resources based economy (e.g., closer economic ties with

EAC countries) Promote the application of EA at the community level to decision making for investments and enterprises for the common good, as a means of advancing local governance systems and sound environmental management.

Environmental guidelines incorporated into sectoral program design and implementation, such as provisions for reconstruction and rehabilitation, invoking environmental good practices:

o MSE & cleaner production o Water & sanitation o road construction and rehabilitation o improved drainage o soil and water conservation o integrated pest management

Environmental awareness and education (IEC) of journalists and parliamentarians

3 EVALUATION of PROJECT/PROGRAM ISSUES Many activities do not have direct adverse environmental impacts, as they entail information, education, communication, training, research, community mobilization, planning, management, and outreach activities. However, in the course of implementing these activities, partners should take advantage of opportunities to address environmental health issues (like hazardous and infectious waste management) with their health service delivery programs.

Certain interventions supported by Health will directly or indirectly affect the environment, or have the potential to do so. Based on analyses conducted by the Health team and by the Mission Environmental Officer, these activities could affect the environment in six ways:

1) Through the procurement, storage, management and disposal of public health commodities, including pharmaceutical drugs;

2) Generation, storage and disposal of hazardous or highly hazardous medical waste, e.g. blood from Voluntary Counseling and Testing (VCT) centers, by-products from tests of Sexually Transmitted Infections (STI) and HIV, blood from malaria and anemia tests, and laboratory-related activities;

3) Small-Scale construction/rehabilitation of health facilities; and

4) Use of pesticides (IVM and Insecticide Treated Pesticides).

Potential impacts of these activities are discussed in detail below.

3.1 Procurement, Storage, Management and Disposal of Public Health Commodities This activity includes procurement of pharmaceutical drugs and vaccines, personal protective gear to prevent communicable disease, family planning products including condoms and intrauterine contracep-tive devices, medical supplies and basic medical equipment, including insecticide treated bed nets. For ITNs, the issue is their inappropriate use as fishing gear. The very small mesh size makes these nets quite non-selective in the size of fish that could be captured.

Pharmaceutical drugs are chemicals used for diagnosis, treatment (cure/mitigation), alteration, or prevention of disease, health condition, or structure/function of the human body. Pharmaceuticals including vaccines have specific storage time and temperature requirements, and may expire or lose efficacy before they are used, particularly in remote areas where demand is low and/or infrequent.

Pharmaceutical waste may also accumulate due to inadequacies in stock management and distribution, and the lack of a routine system of disposal.

Although the pharmaceuticals are designed to interact with bodily functions at low concentrations to elicit specific biological effects in humans, they may also cause biological responses in other organisms. There are many drug classes of concern, including antibiotics, antimicrobials, antidepressants, and estrogenic steroids. Their main pathway to the environment is through household use and excretion, and through the disposal of unused or expired products.

Effects on aquatic life are a major concern in disposal of pharmaceuticals. A wide range of pharmaceuti-cals have been discovered in fresh and marine waters globally, and even in small quantities some of these compounds have the potential to harm to aquatic life. Exposure risks for aquatic organisms are much larger than those for humans because aquatic organisms have continual (and multi-generational) exposures, relative concentrations are higher and there are possible low-dose effects.

Antibiotics, cancer or autoimmune drugs, and undiluted disinfectants should not be disposed of into the sewage system as they may kill bacteria necessary for the treatment of sewage. Additional health risks related to disposal include burning pharmaceuticals and plastic medical supplies (including new or used condoms) at low temperatures or in open containers. This results in release of toxic pollutants to the air. Further, inefficient and insecure sorting and disposal may allow drugs beyond their expiry date to be diverted for resale to the general public. In some countries scavenging in unprotected, insecure landfills is a hazard.

The other commodities covered under this activity are not associated with major health risks, including packaging material, and should be disposed of as solid waste.

3.2 Generation, Storage and Disposal of Hazardous and Highly Hazardous Medical Waste

Small-Scale healthcare activities, such as rural health posts, immunization posts, reproductive health posts, mobile and emergency healthcare programs, and urban clinics and small hospitals, provide important and often critical healthcare services to individuals and communities that would otherwise have little or no access to such services. They are the front line of defense against epidemics such as AIDS, malaria, and cholera and a key component of any comprehensive development program. The medical and health services they provide improve family planning, nurture child and adult health, prevent disease, cure debilitating illnesses, and alleviate the suffering of the dying.

Transmission of disease through infectious waste is the greatest and most immediate threat from healthcare waste. If waste is not treated in a way that destroys the pathogenic organisms, dangerous quantities of microscopic disease-causing agents—viruses, bacteria, parasites or fungi—will be present in the waste. These agents can enter the body through punctures and other breaks in the skin, mucous membranes in the mouth or by being inhaled, swallowed, or transmitted by a vector.

People who come in direct contact with the waste are at greatest risk. Examples include healthcare workers, cleaning staff, patients, visitors, waste collectors, disposal site staff, waste pickers, drug addicts and those who knowingly or unknowingly use “recycled” contaminated syringes and needles.

Healthcare wastes generally fall into three categories in terms of public health risk and recommended methods of disposal:

General healthcare waste, similar or identical to domestic waste, including materials such as packaging or unwanted paper. This waste is generally harmless and needs no special handling;

75–90% of waste generated by healthcare facilities falls into this category, and it can be burned or taken to the landfill without any additional treatment.

Hazardous healthcare wastes including infectious waste (except sharps and waste from patients with highly infectious diseases), small quantities of chemicals and pharmaceuticals, and non-recyclable pressurized containers. All blood and body fluids are potentially infectious. Used con-doms can also contain infectious body fluids, and fall into this category. They should be removed carefully, wrapped so that there is no risk of exposure by waste handlers, and disposed of in a trash receptacle. They should not be flushed down the toilet into either a septic or municipal sys-tem, because the rubber, vinyl or natural products can clog the piping and interfere with the sew-age treatment.

Highly hazardous healthcare wastes, which should be given special attention, includes sharps (especially hypodermic needles), highly infectious non-sharp waste, highly infectious physiologi-cal fluids, pathological and anatomical waste, stools from cholera patients, and bodily fluids of patients with highly infectious diseases. They also include large quantities of expired or unwanted pharmaceuticals and hazardous chemicals, as well as all radioactive or genotoxic wastes.

In any area that produces hazardous waste - hospital wards, treatment rooms, operating theatres, laboratories, etc., three bins plus a separate sharps container will be needed to separate these types of waste. However, if hazardous and highly hazardous waste will be disposed of in the same manner, they should not be collected separately. For hazardous waste and highly hazardous waste the use of double packaging, e.g. a plastic bag inside a holder or container is recommended for ease of cleaning. To make separate collection possible, hospital personnel at all levels, especially nurses, support staff, and cleaners, should be trained to sort the waste they produce.

Although sharps pose an inherent physical hazard of cuts and punctures, the much greater threat comes from sharps that are also infectious waste. Healthcare workers, waste handlers, waste-pickers, drug addicts and others who handle sharps have become infected with HIV/AIDS and hepatitis B and C viruses through pricks or reuse of syringes/needles.

Contamination of water supply from untreated healthcare waste can also have devastating effects. If infectious stools or bodily fluids are not treated prior to disposal, they can create and extend epidemics, since there is very little sewage treatment in Burundi. The absence of proper treatment facilities is believed to have increased the severity and size of cholera epidemics in Africa during the last decade.

Treatment and disposal methods for hazardous and highly hazardous waste may be classified into three categories: thermal processes, chemical processes, and containment processes, or a combination of these methods.

3.3 Small-Scale Construction/Rehabilitation of Health Facilities As with water and sanitation construction activities, some potential environmental impacts are possible with these interventions, and will depend on the local circumstances, including:

Damage to sensitive or valuable ecosystems from construction of infrastructure, associated tem-porary worker dwelling, or construction storage units for personnel or equipment

Removal of vegetation and/or compaction of the soil and grading of the site, altering drainage patterns and water tables, changing access to water by animals, people and vegetation, or degrad-ing water resources

Sedimentation of surface waters through removal of natural land cover, excavation, extraction of construction materials and other construction-related activities that result in soil erosion

Contamination of groundwater and surface water supplies through improper disposal of human and other biological wastes during the construction period

Contamination of ground and surface water supplies through improper disposal or handling of toxic materials used in construction (e.g., solvents, paints, vehicle maintenance fluids (oil, cool-ant), and diesel fuel)

Adverse social impacts due to displacement of local inhabitants, influx of outside workers, ineq-uitable distribution of economic benefits of construction, etc.

Spread of disease through migration of construction workers from other regions or construction of a new road, especially sexually transmitted diseases such as HIV/AIDS

Damage to aesthetics of site/area Improper extraction of construction materials such as wood, stone, gravel, or clay that damages terrestrial ecosystems (e.g., wood may come from relatively intact or natural forests) Use of toxic materials during construction

3.4 Use of Pesticides

Use of any pesticide is of major concern because of the potential for both health and/or environmental effects. Pesticides can cause short-term adverse health effects, called acute effects, as well as chronic adverse effects that can occur months or years after exposure. Examples of acute health effects include stinging eyes, rashes, blisters, blindness, nausea, dizziness, diarrhea and death. Examples of known chronic effects are cancers, birth defects, reproductive harm, neurological and developmental toxicity, immunotoxicity, infertility and other reproductive problems; disruption of the endocrine system, and damage to the liver, kidneys, lungs and other organs. Chronic effects may not appear for weeks, months or even years after exposure, making it difficult to link health impacts to pesticides.

Some people are more vulnerable than others to pesticide impacts. For example, infants and young children are known to be more susceptible than adults to the toxic effects of pesticides. Exposure during certain early development periods can cause permanent damage. Children are more vulnerable because their organs, nervous systems and immune systems are still developing, and they have higher rates of cell division and lower body weight than adults. In addition to being more vulnerable to pesticide toxicity, children's behavior and physiology make them more likely to receive greater pesticide exposure than adults. Most pesticide exposure occurs through the skin, and children have more skin surface for their size than adults. Children have a higher respiratory rate and so inhale airborne pesticides at a faster rate than adults. Children also consume proportionately more food and water -- and pesticide residues -- than adults. With their increased contact with floors, lawns and playgrounds, children's behavior also increases their exposure to pesticides.

People with asthma may have very severe reactions to some pesticides, particularly pyrethrin/pyrethroid, organophosphate and carbamate pesticides. Farm workers and pesticide applicators are also more vulnerable because they receive greater exposures, sometimes due to inadequate protective equipment or training. In many cases, symptoms of pesticide poisoning mimic symptoms of colds or the flu. Since pesticide-related illnesses appear similar or identical to other illnesses, pesticide poisonings are often misdiagnosed and under-reported. Immediate symptoms may not be severe enough to prompt an individual to seek medical attention, or a doctor might not even think to ask about pesticide exposure.

The persistence of a pesticide in the environment is determined by a number of factors including (1) the amount introduced and how it is distributed; (2) its reactivity in the environmental media; and (3) the conditions of the media. These factors help determine the concentration of pesticide in the air, soil, water, plants, and animals. Pesticides applied to enclosed areas, such as greenhouse spaces, and public and private buildings, usually break down at a slower rate than those applied outdoors.

Over time, the pesticides may (1) break down, (2) be redistributed around the application site or (3) move off site. Off site movement includes movement to groundwater, surface water, or the atmosphere, and also includes residues that remain on crops or livestock when they are removed from the site.

All pesticides react in the environment to form new chemicals but the rate at which they react and the products formed during breakdown are important. In addition to chemical reactions, all pesticides are subject to breakdown in the presence of sunlight.

In distribution of long-lasting insecticide-treated bed nets, the environmental impact potential is expected to be exceedingly small. Risks presented by the use of pre-treated nets include the following: 1) potential adverse impacts on aquatic organisms if large numbers of nets (100+) are washed in a river, stream or pond at the same time; 2) the small potential for adverse health effects in net users. Regarding the latter, the only impact expected to periodically occur is skin irritation among some users when the net is new, an effect that subsides rapidly and causes no long-lasting harm. Both types of risks are very small, and were found in the Global Health Programmatic Environmental Assessment to be greatly outweighed by the malaria prevention benefits stemming from the use of insecticide-treated materials.

4. Threshold determinations and Mitigation Measures

Table 1: Threshold determinations and attached Conditions for each activity group Activities in Burundi Impact Issues & conditions, mitigation or proactive interventions Activities in Group 1: Categorical Exclusion

HIV/AIDS

Enhancing behavior change communications: Promoting correct and consistent condom use; Supporting activities against gender discrimination and GBV through income generating activities; Providing nutritional support to HIV positive mothers during the weaning period; and Supporting performance-based financing.

MCH

Building the capacity of national authorities and provinces for data; Increasing the skills for maternal and child health; antenatal care and birth preparedness, emergency obstetric care, integrated management of childhood illnesses, routine immunizations, growth monitoring, and young child nutrition;

Supporting BCC; and Supporting the decentralization process through performance-based financing approach.

FP/RH

Improving the reproductive services; Supporting BCC activities; increasing counseling and family planning services for women living with HIV; and Supporting health coordination at the national, provincial, and district levels.

Malaria Improving the national entomological surveillance capacity; strengthening the capacity; strengthening anti-malaria drug quality monitoring and surveillance;

supporting the in-country supply; developing a national malaria control monitoring and evaluation plans;

Categorical Exclusion, per 22 CFR 216.2 (c)(2)(i), education, technical assistance or training; 216.2 (c)(2)(iii): analyses, studies, academic or research workshops and meetings; 216.2 (c)(2)(v): document and information transfers; 216.2(c)(2)(viii): programs involving nutrition, health care, or family planning services except to the extent designed to include activities directly affecting the environment (such as construction of facilities, water supply systems, waster water treatment, etc).Will not have a direct effect on the environment.

No further environmental review required.

A Negative Determination with Conditions recommended pursuant to 22 CFR 216.3(a)(2)(iii) for the following activities in Activity group 2 to 6 Activity group2 that involve: Generation, storage, handling and disposal of hazardous and highly hazardous medical waste HIV/AIDS: Reinforcing the laboratory system by supplying reference laboratories with equipment and reagents for biological follow-up including hematology and biochemistry for HIV+ pregnant women and people under ART and through training and supervision of lab technicians; improving access to voluntary testing and counseling as well as provider-initiated testing and counseling (PITC);

Conditions:

For all USAID-supported activities entailing service delivery, including blood testing and laboratory support, USAID/Burundi Health team will work with its implementing partners to assure, to a reasonable extent possible, that the medical facilities and operations involved have adequate procedures and capacities in place to properly handle, label, treat, store, transport and properly dispose of blood, sharps and other medical waste.

Activities in Burundi Impact Issues & conditions, mitigation or proactive interventions increasing access to PMTCT services; supporting a modest male circumcision program; expanding interventions relating to post-exposure prophylaxis (PEP) in cases of rape, occupational exposure, and for the prevention of MTCT;

Malaria: Supporting confirmed diagnosis of malaria at facility and community level before treatment by procuring rapid diagnostic tests, supporting high quality microscopy, and strengthening provider adherence to malaria diagnostic results;

The team…