ATTACHMENT J.14 #U2013 INITIAL ENVIRONMENTAL EXAMINATION IHO OFFICE PORTFOLIO.pdf

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 1

ATTACHMENT J.14

INITIAL ENVIRONMENTAL

EXAMINATION

APPROVAL DOCUMENT

PROGRAM/ACTIVITY DATA:

Program/Activity Number: --- Program Activity Title: USAID/Mozambique Integrated Health Office Portfolio

IR 4.1: Increased Coverage of High Impact Health and Nutrition Services (Health Service Delivery)

Country/Region: Mozambique

Functional Objective: Investing in People Program Elements: 3.1.1, 3.1.7, 3.1.6, 3.1.3, 3.1.9, 3.1.2, 3.1.8 (PEPFAR, FP, MCH, PMI, NUTRITION, TUBERCULOSIS, WASH)

Period Covered: 2014–2019 LOP Amount $479 million

IEE Prepared By: Josh Habib & Kathleen Hurley, GEMS/The Cadmus Group, Inc.

Josh.Habib@cadmusgroup.com

IEE Amendment (Y/N): No Submitted By: Juno Lawrence Jaffer – Division Chief, Maternal and Child Health, Family

Planning, Malaria, & Nutrition Current Date December 2014 Expiration Date November 2019

Other Relevant Environmental Compliance Documentation: USAID/Mozambique Integrated Health Office Portfolio IEEs for 2014-2019: Strengthened Systems to Deliver Health, Nutrition, and Social Services and Increased Adoption of Positive Health and Nutrition Behaviors.

ENVIRONMENTAL ACTION RECOMMENDED

Categorical Exclusion X Negative Determination X

Positive Determination Deferral X

ADDITIONAL ELEMENTS:

EMMP: X | Conditions: X | PVO/NGO: | Pesticides:*

*22 CFR 216.3 (b)(1) applies

SUMMARY OF FINDINGS:

Scope. This IEE addresses the entire portfolio of activities anticipated under IR 4.1: Increased Coverage of High Impact Health and Nutrition Services of the USAID/Mozambique Health Status of Targeted Population Groups Improved (D04) portfolio. It applies to all health Service Delivery activities implemented under Mozambique’s 2014–2018 CDCS and Project Appraisal Document (PAD). It replaces

SOL-720656R00008 Efficiences for Clinical HIV/AIDS Outcomes (ECHO)

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 2 and supercedes the Mission’s previous IEEs; except that ongoing activities operating an approved environmental mitigation and monitoring plan (EMMP) may continue operating under that EMMP.

Note that there are activities discussed in the Service Delivery PAD that are not covered in this IEE because they are more appropriately covered in one of the other two health sector IEEs. For instance, social and behavior change communication (SBCC) activities are addressed in the IEE on Communication Improves Health Outcomes (IR 4.2) and procurement and supply chain strengthening activities (e.g., supply chain management to increase availability of drugs to prevent malaria) are covered in the Health Systems Strengthening (IR 4.3) IEE.

To help ensure that they are clearly distinguishable, the three IEEs for the Integrated Health Office (DO

4) portfolio (vis-a-vis what aspects of the IHO program are covered in which IEE), the below table summary will help keep things straight:

USAID/Mozambique Integrated Health Office Portfolio (2014-2018 CDCS):

Health Status of Targeted Populations Groups Improved (DO4)

IR Title Short Title, acronym (if any)

4.1 Increased Coverage of High-Impact Health and Nutrition

Services [THIS IEE]

Health Service Delivery (no acronym)

4.2 Increased Adoption of Positive Health and Nutrition

Behavior

Communication for Improved Health Outcomes (CIHO)

4.3 Strengthened Systems to Deliver Health, Nutrition, and

Social Services

Health Systems Strengthening

(HSS)

Recommended Determinations. The following table summarizes the recommended determinations for the health portfolio, per the intervention categories established by this IEE for purposes of environmental review. For each, a link is provided to the entailed activity descriptions, analysis of potential environmental impacts, and activity-by-activity determinations and conditions within section 3 of the IEE.

Intervention Category Categorical

Exclusion(s)

Negative

Determination(s)

Positive

Determination(s)

Deferral of

Threshold

Decision

Link to full analysis

Healthcare Worker/Delivery Agent

Training; Healthcare Workforce

Strengthening & Development

X

Click here

Direct & Capacity-Building Support for Delivery & Equitable Access to

Health Services; Technical Assistance

To Improve Prevention Efforts

X X

Water and Sanitation for Health

(WASH)

X X X Click here

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 3

Construction other than

Water/Sanitation Infrastructure X X Click here

Studies, Surveys/Public Health

Surveillance & other Data-Gathering

Assessments & Models

X X

General Implementation & Monitoring Conditions. In addition to the specific conditions enumerated in Section 3, the negative determinations recommended in this IEE are contingent on full implementation of a set of general monitoring and implementation requirements specified in Section 4 of the IEE.

These require, in summary: (1) IP Briefings on Environmental Compliance Responsibilities; (2) Development of environmental mitigation and monitoring plans (EMMPs); (3) Integration and implementation of EMMPs in workplans and budgets; (4) Integration of compliance responsibilities in prime and sub-contracts and grant agreements; (5) Assurance of sub-grantee and sub-contractor capacity and compliance; (6) Health Team environmental compliance monitoring; (7) 22 CFR 216 documentation coverage for new or modified activities; (8) compliance with host country requirements, and (9) Government-to-government (G2G) assistance.

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 5

INITIAL ENVIRONMENTAL EXAMINATION

PROGRAM/ACTIVITY DATA:

Program/Activity Number: Health Service Delivery (Activity Number not applicable at this level)

Program Activity Title: USAID/Mozambique Integrated Health Office Portfolio Increased Coverage of High Impact Health and Nutrition Services

Country/Region: Mozambique/ Africa

Functional Objective: Investing in People Program Area: 3.1 Health Program Elements: 3.1.1, 3.1.7, 3.1.6, 3.1.3, 3.1.9, 3.1.2, 3.1.8 (PEPFAR, FP, MCH, PMI, NUTRITION, TUBERCULOSIS, WASH)

1.0 BACKGROUND AND PROGRAM DESCRIPTION

1.1 PURPOSE AND SCOPE OF IEE

This IEE addresses the portfolio of activities anticipated under the USAID/Mozambique Health Service Delivery portfolio. The service delivery portfolio is defined by Intermediate Result (IR) 4.1 in support of the mission’s Development Objective 4 (D04), “Health status of targeted population groups improved” and includes all activities implemented under the “USAID/Mozambique 2014-2019 Health Services

Delivery Project Appraisal Document: Increased Coverage of High Impact Health and Nutrition Services” (PAD).

The Service Delivery portfolio of activities will operate in parallel with IR 4.2: Increased Adoption of Positive Health and Nutrition Behaviors and IR 4.3: Strengthened Systems to Deliver Health, Nutrition, and Social Services.

Note that there are activities discussed in the Service Delivery PAD that are not covered in this IEE because they are more appropriately covered in one of the other two health sector IEEs. For instance, social and behavior change communication (SBCC) activities are addressed in the IEE on Communication Improves Health Outcomes (IR 4.2) and procurement and supply chain strengthening activities (e.g., supply chain management to increase availability of drugs to prevent malaria) are covered in the Health Systems Strengthening (IR 4.3) IEE.

This IEE, together with IEEs developed for IR 4.2 and IR 4.3, replaces and supersedes the Mission’s “Improving the Health of Mozambicans” Health Sector IEE (FY 2009-2014); except that ongoing activities operating an approved environmental mitigation and monitoring plan (EMMP) may continue operating under that EMMP.

As with all IEEs, and in accordance with 22 CFR 216, this IEE reviews the reasonably foreseeable effects of subject activities on the environment. On this basis, this IEE recommends Categorical Exclusions or Threshold Decisions for these activities. Upon approval of this IEE, these recommendations become affirmed Categorical Exclusions and Threshold Decisions, and implementation of recommended conditions becomes mandatory.

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 6

In addition, this IEE sets out project1-level implementation procedures intended to assure that conditions in this IEE are translated into activity-specific mitigation measures, and to assure systematic compliance with this IEE during project and program implementation. These procedures are themselves a general condition of approval for the IEE, and their implementation is therefore mandatory.

This IEE is a critical element of a mandatory environmental review and compliance process meant to achieve environmentally sound activity design and implementation.

1.2 PROGRAM BACKGROUND: CONTEXT & JUSTIFICATION

The main public health system challenges in Mozambique include inadequate infrastructure and funding for health facilities and supplies, a shortage of health workers, an overreliance on donors for health financing, deficient information systems, and a weak civil society that does not hold the Government of the Republic of Mozambique (GRM) accountable for health service provision. E.g.:

Per 100,000 people there are only 6.5 doctors, 28 nurses, and a total of 66 health care workers, a proportion that is among the lowest in the world.

Multi-drug resistant tuberculosis rate and national HIV prevalence rates are both very high, at 3.5% and 11.5%, respectively.

High child and maternal mortality rate reflect the difficulty women and children have in accessing essential health services (e.g., fewer than half of households have access to a health center less than 45 minutes away).2

Mozambique is one of the countries selected as a Global Health Initiative (GHI) country under President Obama’s six-year, US$63 billion health initiative. Under GHI, the U.S. and Mozambique will work to reduce maternal, newborn, and child mortality in rural populations by: strengthening governance in the health sector; improving retention and management of the health workforce; and expanding access and uptake of quality maternal, newborn, and child health services.

In conjunction with health system strengthening and nutrition and health behavioral activities, USAID/Mozambique Service Delivery activities aim to respond to these human and development health needs. The service delivery portfolio includes goals of increasing utilization of quality community-level and facility-level services, and improving active and completed referrals between community and facility services. In particular, USAID/Mozambique proposes activities to scale-up the delivery of evidence-based, high impact interventions to address the key causes of mortality and morbidity in target populations.

1 The terms “activity” and ‘project” are used throughout this IEE per their standard meaning in environmental impact assessment, and NOT as per USAID’s new programming framework. As such, a project is a cluster of activities executed under a single, thematically focused prime contract or award. By contrast, in USAID’s new programming framework, “project” describes a sector- or sub-sector portfolio, covering multiple contracts or awards, and “activity” denotes a single such contract or award (“implementation vehicle.”) 2 USAID/Mozambique Health Service Delivery PAD, 17 October 2014.

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 7

1.3 SUMMARY OF ACTIVITIES

The program areas supported by service delivery are malaria; maternal, newborn, and child health (MNCH); family planning; nutrition; HIV/AIDS; tuberculosis (TB); and water, sanitation, and hygiene (WASH). The populations targeted include: most-at-risk children under five, pregnant and lactating women, those infected with or affected by HIV/AIDS, and other at-risk groups (including youth, truck drivers, sex workers and orphans and vulnerable children [OVC]).

According to the USAID/Mozambique Health Service Delivery PAD (17 October 2014), the prospect of improved health services delivery in Mozambique is based on the proposed approach that coverage of health and nutrition services will increase if access to facility-level and community health services expands, and if referrals between community and facility services are improved. To supplement the primary IR 4.1—increased coverage of high impact health and nutrition services—the PAD identified three sub-IRs:

4.1.1 Increased utilization of quality facility-level services

4.1.2 Increased utilization of quality community-level services

4.1.3 Improved active and completed referrals between community and facility services.

The PAD also notes that, within the three sub-IRs, problems of access and equity of health services, quality and efficiency of health programs and services, and the availability of qualified personnel, can inhibit progress towards delivering critical health services to the population.

1.4 INTERVENTION CATEGORIES FOR PURPOSES OF ENVIRONMENTAL REVIEW

Neither the sub-IRs listed nor the intervention program areas (malaria, MNCH, etc.) listed immediately above constitute conducive activity categories for environmental review. Organizing environmental analysis either by sub-IRs or program areas would entail significant repetition of analysis for similar activities in different categories, and thus a long and unwieldy document.

Accordingly, for purposes of environmental review and compliance, this IEE organizes interventions in the USAID/Mozambique Health Service Delivery portfolio into five intervention categories. Each has activities from one or more IRs:

1. Healthcare Worker/Delivery Agent Training; Healthcare Workforce Strengthening & Development

2. Direct & Capacity-Building Support for Delivery & Equitable Access to Health Services; Technical Assistance To Improve Prevention Efforts

3. Water and Sanitation for Health (WASH)

4. Construction other than Water/Sanitation Infrastructure

5. Studies, Surveys/Public Health Surveillance & other Data-Gathering Assessments, Models, &

Capacity-Building.

Each intervention category has a number of entailed activities; these are set out, and, where not self-explanatory, annotated in Section 3 of this IEE.

Note: there are activities discussed in the PAD that are not directly addressed in this IEE because they are more appropriately covered in one of the other two health sector IEEs. For instance, social and behavior change communication (SBCC) activities are addressed in the IEE on Communication Improves Health Outcomes (IR 4.2) and procurement and supply chain strengthening activities (e.g., supply chain

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 8 management to increase availability of drugs to prevent malaria) are covered in the Health Systems Strengthening (IR 4.3) IEE.

2.0 COUNTRY AND ENVIRONMENTAL BASELINE INFORMATION

2.1 MOZAMBIQUE ENVIRONMENTAL PROFILE

Geography. Mozambique is located in Southeastern Africa along the Indian Ocean. It is separated from Madagascar by the Mozambique Channel and is bordered to the north by Tanzania, to the west by Zambia, Malawi, and Zimbabwe, and to the South by Swaziland and South Africa. Total land area is almost 800,000 km2, with 2,470 km of coastline.3 Generally, the country is low lying, with coastal plains covering about 42% of land, mainly in the south and along the coast. Twenty-nine percent of the country is covered with plateaus, while 25% is highlands ranging from 500 to 1000 meters in the north and west.

Around 25 rivers flow through Mozambique, exiting in the Indian Ocean. The Zambezi River is the largest, and cuts across central Mozambique. 4

Climate. Mozambique’s climate is semi-arid and subtropical in the south and tropical in the north. There is a warm, wet season from November to March and a dry, cooler season from April to October. Climate is influenced by altitude, latitude, and proximity to the sea. Mozambique receives from about 300 to 2,000 millimeters of rain per year, depending on location. The lowlands in the southern interior typically receive less rain than the Zambezi Delta and the Mountainous areas in the north and west. Droughts and floods are common as precipitation varies significantly from year to year.

Ecosystems. The main terrestrial ecosystem in Mozambique is the Miombo woodlands, dry tropical woodlands consisting of broad-leaved trees. Mozambique also has 13,400 km2 of coastal forest located from the northern border to the Zambezi river. The Mopane woodlands, dominated by the Mopane tree, are located in Western Mozambique in the Zambezi Valley and in the southwestern Gaza Province. In the dry southern areas of Mozambique where tree canopy cover is less than 20%, ecosystems consist of savanna grassland and thorn scrub vegetation. In western Mozambique and the northern Tete Province, the montane ecosystems include evergreen forests and afroalpine grasslands, shrublands and moorlands at the highest elevations.

The main freshwater and wetland ecosystems in Mozambique are rivers and their riparian zones, deltas, natural lakes and artificial lakes created by dams. Lake Niassa and the Zambezi Delta are important examples. Lake Niassa

3 CIA World Factbook, Mozambique 4 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on September 18 at: http://pdf.usaid.gov/pdf_docs/PNAEA332.pdf

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 9 is the southernmost Rift Valley Lake and is famous for its endemism, mainly the cichlid fish. The Zambezi delta was nominated as a Ramsar site, and supports a large population of aquatic birds, heron and ducks. It is also an important breeding ground for the wattled crane, and a temporary home to thousands of migratory species that depend on the habitat. Certain species in the delta habitats are also endangered, threatened, or of important commercial value. Some of the largest and most important lakes for biodiversity, fisheries and tourism include Lake Bilene, Nhambavale, Quissico, Inharrime, and Piti. These lakes are important feeding and breeding grounds, but are threatened by unregulated development, pollution and tourism.

Coastal and marine ecosystems occupy 572,000 km2 of Mozambique’s total area and consist of dunes, beaches, seagrass beds, coral reefs, and mangroves. The dunes between Bazaruto Island and Ponta do Ouro are considered the tallest vegetated dunes in the world; the flora is diverse and the area contains many medicinal plants for local communities. Sandy beaches are home to five species of endangered marine turtles, as well as ghost crabs and coastal birds. These ecosystems are also under stress from unregulated development, tourism, and deforestation. Thirteen species of seagrass beds have been identified, and are important as a nursery and feeding area for sea turtles, dugongs, and other commercially valuable species. Coral reefs are located along the northern coast, mainly fringing reefs with hard corals and rich biodiversity. About 300 species of hard corals and 50 species of soft corals have been identified. Small-scale fisheries depend on these reefs and associated ecosystems, as well as a growing tourism industry in the south, where Scuba diving is popular. Nine different species of mangrove trees have been identified in Mozambique. Mangrove forests are located on sheltered areas of the coast, mainly the estuaries and deltas of the Zambezi, Púnguè, and Save Rivers, and are important for local community use and ecosystem services, such as coastal protection. 5

Soils. Granite rock underlies most of northern and west-central Mozambique, while the soils of southern and east-central Mozambique are sedimentary. The northern and central regions have more fertile, water-retentive soils with a higher content of red clay. In the south, soils are mostly sandy and infertile;

fertile soils are limited to alluvials in the valleys of the Save, Limpopo, Incomáti, Umbelúzi, and Maputo rivers. 6

Water Resources. Mozambique has abundant water resources due to its major river systems which also offer hydroelectric and irrigation potential. The Rovuma River lines Mozambique’s northern border with Tanzania while the Zambezi River and its tributaries are found in the central region. The Zembezi has 819 km in Mozambique and drains more than 225,000 km2 of the central region. The southern border with Swaziland and South Africa is formed partly by the Maputo River. Other drainage areas include the Messalo, Púngoè, Revuè, Buzi and Limpopo rivers. Mozambique shares several lake borders with Malawi (Nyasa, Chiuta and Chilwa) but has no other important lakes besides those created by the hydroelectric dam network. 7

Mozambique has considerable groundwater potential with well yields in the Zambezi and Incomati basins at 70,000 m3 per day. Seventeen km3 of groundwater is produced annually and 97.3 km3 of surface water. Including some overlap between ground and surface water, total renewable water sources equal around 100.3 km3 per year. The Cahora Bassa dam on the Zambezi River is the largest

5 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on September 18 at: http://pdf.usaid.gov/pdf_docs/PNAEA332.pdf 6 Mozambique, Accessed via the internet on 19 September at:

http://www.britannica.com/EBchecked/topic/395363/Mozambique#toc43964 7 Mozambique, Accessed via the internet on 19 September at:

http://www.britannica.com/EBchecked/topic/395363/Mozambique#toc43964

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 10 hydroelectric plant in southern Africa with an installed capacity of 2,060 MW. Surface water is the main water source in Mozambique, although groundwater is used for drinking water supply in certain urban areas. In rural areas, shallow wells and handpump-mounted boreholes are the main source of drinking water.

The greatest source of water withdrawal is agriculture, where irrigation withdrew 86.6% in 2000, mainly from surface water, the main source of water in Mozambique. In 2003, 1,181 km2 was irrigated. Total irrigation potential is around 3,300,000 ha, where the main areas suitable for irrigation are the center and the north of the country. The Zambezia province is home to 60% of the irrigation potential. Most irrigated lands are occupied by smallholder farmers and agricultural enterprises. Small-scale irrigation schemes exist all over the country, but are mostly abandoned or in bad condition due to the civil war, lack of inputs and technical assistance, and floods in 2000 and 2001. 8

Biodiversity & Protected Areas. Mozambique is home to 5,500 plants, 581 birds, and 205 mammals.

About 250 of these species are endemic to Mozambique. Five species of sea turtles occur along the coast, and eighteen other species of marine animals including dolphins, whales, seals, and dugong.

Around 300 species of plants are on the “Red List” of threatened and endangered species, 55 of which are endemic to Mozambique. In addition, 105 mammal species are of conservation concern. The white renoceros, tsesebe, sitatunga, black rhinoceros, giraffe, roan antelope, mountain reedbuck, and cheetah are the most threatened large mammal species. The Gorongosa Mountains, Great Inselberg Arcihpelago of Quirimbas and the Chimanimani Mountains are all sites of high importance for biodiversity. 910

Mozambique has extended its protected areas from 11% to 25% of its national area, and has added new conservation areas as well, such as Quirimbas National Park for marine and coastal ecosystems and Limpopo Transfrontier National Park. Several areas are also under special protection, including Marromeu Complex, Maputoland Centre of Endemism, and the Chimanimani and Namuli Mountains. 11 Overall, protected areas include six national parks, eight national reserves, 13 forest reserves, two integral reserves, and 14 hunting concession designated for sport hunting and protecting species. In addition, the Marromeu Natural Reserve and Lake Niassa Partial Reserve are Ramsar sites due to the extensive biodiversity of their wetlands. 12Mozambique has one UNESCO Cultural World Heritage Site, the Island of Mozambique. 13

2.2 HEALTH AND HEALTH SECTOR PROFILE

Mozambique has made advances towards reaching its health-related Millennium Development Goals, but access to basic services remains low. Neonatal mortality decreased to 30 deaths/1000 and under-give morality to 90 deaths/1000. However, in other areas health outcomes are still substandard. Malaria causes 26% of hospital deaths, HIV prevalence is still high, the national TB response is complicated by multi drug TB resistance (Mozambique is among the 22 high-burden TB countries), and women and

8 Mozambique, accessed via the internet on 19 September at:

http://www.fao.org/nr/water/aquastat/countries_regions/moz/index.stm 9 Mozambique-Country Profile, accessed via the internet on 18 September at:

http://www.cbd.int/countries/profile/default.shtml?country=mz#status 10 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on

September 18 at: http://pdf.usaid.gov/pdf_docs/PNAEA332.pdf 11 Mozambique-Country Profile, accessed via the internet on 18 September at:

http://www.cbd.int/countries/profile/default.shtml?country=mz#status 12 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on

September 18 at: http://pdf.usaid.gov/pdf_docs/PNAEA332.pdf 13 Mozambique- Properties inscribed on the World Heritage List, accessed via the internet on September 18 at:

http://whc.unesco.org/en/statesparties/MZ/

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 11 children have inadequate access to health services. In addition, recurrent natural disasters and epidemics exacerbate health system issues and require stronger surveillance systems and accordance with international health regulations. 14

In 2013, the number of people living with HIV in Mozambique was 1.6 million. Adults have a 10.8% prevalence rate, while 190,000 children aged 0 to 14 are living with HIV. In 2013, around 82,000 people died from AIDS.15 Only 40% of HIV+ pregnant women received Anti-Retroviral Therapy (ART) for their own health, while 86% received ART for Prevention of Mother-to-Child Transmission. 16 From 2004 to 2009, the number of children receiving ART increased from 500 to 12,647, representing 27% of children eligible for and requiring treatment.17

The high child and maternal mortality rate is a reflection on the difficulty women and children have in accessing essential health services. The main causes of death for children under five are neonatal death (34%), Malaria (18%), “other” (16%), and Sepsis (Tetanus, Meningitis, Encephalitis- 7%). The main causes of maternal death are indirect (29%), hemorrhage (25%) and hypertension (16%). In 2011, only 54% of live births were attended by skilled health personnel. Disease prevention and treatment in children is another challenge. Around 56% of children under five with diarrhea received treatment in 2011, while less than 40% of children slept under insecticide-treated nets. Nutrition is also a major issue among children, as 43% have stunted growth, and 16% are moderately or severely underweight. 18

National water supply coverage in Mozambique was 47% in 2008, 77% in urban areas and 29% in rural areas. Sanitation coverage was 17%, with major differences again among urban (38%) and rural (4%) areas. Urban water and sanitation infrastructure will face increasing challenges as urban population growth increases at a rate or 4% each year. Mozambique’s water vulnerability is represented by its reliance on upstream neighbors for 50% of surface water. Further, climate change has implications for both food and water security as analysis suggests that Mozambique will face warming in inland regions and sea level rise along the coast. The government recognizes the role water and sanitation plays in reducing poverty levels, and has addressed water, sanitation and hygiene issues in its Five Year Plan (2010-2015), Poverty Reduction Action Plan, and UN Development Assistance Framework. 19

2.3 ENVIRONMENTAL INSTITUTIONS, POLICY AND REGULATION

Environmental regulations in Mozambique begin with the Constitution of 2004, which addresses the environment and quality of life, and states “the state and local authorities, in collaboration with out appropriate partners, to adopt policies for the protection of the environment and care for the rational utilization of all natural resources”. It also claims that the state shall adopt policies to prevent and control pollution and erosion, integrate environmental objectives into sector policies, promote the integration of environmental values in educational policies and programs, and ensure the rational and sustainable utilization of natural resources.

14 Mozambique Country Cooperation Strategy at a Glance, accessed via the internet on 22 September 2014 at:

http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_moz_en.pdf 15 Mozambique HIV and AIDS estimates (2013), accessed via the internet on 22 September 2014 at:

http://www.unaids.org/en/regionscountries/countries/mozambique/ 16 http://www.unaids.org/en/regionscountries/countries/mozambique/ 17 Mozambique Maternal, Newborn & Child Survival, accessed via the internet on 22 September 2014 at:

http://www.countdown2015mnch.org/documents/2014Report/Mozambique_Country_Profile_2014.pdf 18 Mozambique Maternal, Newborn & Child Survival, accessed via the internet on 22 September 2014 at:

http://www.countdown2015mnch.org/documents/2014Report/Mozambique_Country_Profile_2014.pdf 19 Mozambique WASH Sector Brief, accessed via the internet on 22 September 2014 at:

http://www.ircwash.org/sites/default/files/ISF-2011-Mozambique.pdf

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 12

In Mozambique, the Ministry of Environmental Coordination (MICOA) is responsible for implementing the National Environmental Management Program (NEMP) and associated environmental legislation, and for coordinating with other ministries to integrate environmental aspects into their projects and policies. The NEMP was formulated by MICOA in 1996 and contained an Environmental Policy, a proposal for the Framework Environmental Act (passed in 1997) and an Environmental Strategy. MICOA has established regulations relating to environmental management including for industrial activities, mining, standards for environmental quality and effluent emissions, and environmental auditing. MICOA is also responsible for regulating Environmental Impact Assessments (EIAs) which involves approving the terms of reference, reviewing completed EIAs and implementing an audit process.

The Environmental Law of 1997 is the basis of all legislation regarding preservation of the environment.

The law’s objective is to define the legal basis for judicious utilization and management of the environment, aiming to achieve sustainable development in Mozambique. The law’s mandate includes public and private activities that have any risk of influencing the environment. The principles set out by this law are rational and sustainable management and use of the environment for the maintenance of biodiversity and ecosystems and improvement of quality of life for citizens; recognition of traditions and local knowledge which may contribute to the conservation and preservation of natural resources;

precaution for activities that might harm the environment; an integrated, global vision of the environment; public participation; equitable access to natural resources by all; and commitment to minimizing trans-boundary impacts. Chapter four of this law, Prevention of Environmental Damage, requires licensing of activities likely to cause environmental impacts. Issuance of a license depends on an EIA being completed and accepted by MICOA.

Mozambique has several laws that provide the legal framework for ownership and management of environmental resources, such as forests, land, and water. Mozambique’s Forestry and Wildlife Policy, Law, and Regulations confirm the State’s mandate over natural forests and wildlife resources, calls for establishing protected areas to conserve biodiversity, and provides guidelines for the sustainable use of these resources. The Forestry and Wild Law regulations include licensing details and information about exploitation, game farms, and fines. The Land Act provides the legal framework for land and natural resource ownership in Mozambique. It establishes that surface and groundwater belong to the state and people of Mozambique, and requires a license for use of large quantities of water. It also recognizes the need to create protected areas for ecologically sensitive land and natural resources. The Water Law in Mozambique established the state’s ownership of inland surface and groundwater and requires a license for the use of large quantities of water for industry, irrigation or other purposes. Licenses are granted if the water use does not cause significant environmental damages. These laws acknowledge the rights of local communities over land and natural resources, and encourage their involvement in management and conservation. 20,21

Mozambique is a member of the World Bank and IUCN, and therefore should follow these organization’s guidelines related to biodiversity conservation. In addition, Mozambique is party to multiple international conventions and protocols to protect the environment, including the convention on the International Trade in Endangered Species of Wild Flora and Fauna (CITES), the Vienna and Montreal Conventions for protection of the Ozone, the Kyoto Protocol, the UN Convention on Biological Diversity, the Cartagena Protocol on Biosafety, the Convention on Persistent Organic Pollutants (POPs), the UN

20 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on

21 Mozambique, accessed via the internet on 22 September at: http://www.saiea.com/saiea-book/mozam1.pdf

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 13

Framework Convention on Climate Change, and the Bamako Convention on the Ban of the Import into Africa and the Control of Transboundary Movements of Hazardous Wastes within Africa. 22

2.4 REGULATIONS RELEVANT TO THE HEALTHCARE SECTOR

Mozambique’s Regulation for the Prevention of Pollution and Marine and Coastal Environmental establishes the legal basis for protection and conservation of seas, lakes, rivers, beaches and fragile ecosystems, and limits pollution resulting from discharge by ships, platforms, or land-based sources along the coast. It also prohibits the discharge of toxic or harmful wastewater or substances that may cause pollution.

In 2006 Mozambique passed the Regulation on Waste Management to encourage waste producers to minimize waste. It establishes rules related to production and discharge of toxic and polluting substances as well as activities that degrade the environment.

The Regulation regarding Standards for Environmental Quality and the Discharge of Effluent defines standards for environmental quality and effluent emission for receiving bodies of water, treatment technologies, systems and methods. It requires that liquid industrial effluent by discharged through an appropriate entity in accordance with emission and discharge standards, and that the point of discharge is determined during the environmental licensing process so the water quality of the receiving body will be unchanged.

The Regulation regarding the Quality of Water for Human Consumption establishes water quality parameters for human consumption, and procedures for controlling water quality to protect human health. 23

3.0 POTENTIAL ENVIRONMENTAL IMPACTS & RECOMMENDED

DETERMINATIONS, INCLUDING CONDITIONS

As set out in section 1.4, for the purpose of environmental review, activities of the Service Delivery program addressed by this IEE are grouped into the following intervention categories.

1. Healthcare Worker/Delivery Agent Training; Healthcare Workforce Strengthening & Development

2. Direct & Capacity-Building Support for Delivery & Equitable Access to Health Services; Technical Assistance To Improve Prevention Efforts

3. Water and Sanitation for Health (WASH)

4. Construction other than Water/Sanitation Infrastructure

5. Studies, Surveys/Public Health Surveillance & other Data-Gathering Assessments & Models.

Each category contains a number of entailed activities. In sections 3.2-3.6, the entailed activities are described and their potential impacts analyzed. On this basis, Recommended Determinations are made.

In most cases, Negative Determinations entail conditions. Upon approval of this IEE, implementation of these conditions becomes mandatory.

22 Mozambique Environmental Threats and Opportunities Assessment, January 2013, accessed via the internet on

23 http://www.erm.com/PageFiles/13352/Draft-EIA-Aug2013/Chapter-2-LNG.pdf

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 14

3.1 ADVERSE IMPACTS OF HEALTH SERVICES DELIVERY DUE TO FAILURE TO PROPERLY

MANAGE RESULTING WASTES

This section is a general discussion and analysis of waste-related impacts of health care service delivery.

It is referenced at several points in the analyses of the specific intervention categories that follow in sections 3.2—3.6. It supports this subsequent analysis; no recommended determinations are attached specifically to this section.

Although healthcare activities provide many important benefits to communities, they can also unintentionally do harm via poor management of the wastes they generate. These 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.

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

Pharmaceutical Wastes and Medical Supplies, including condoms: Pharmaceutical drugs 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/or lack of a routine system of disposal.

The effects of pharmaceutical waste in the environment are different from conventional pollutants.

Drugs are designed to interact within the body at low concentrations to elicit specific biological effects in humans, and which 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 into the environment is through household use and excretion, and through the disposal of unused or expired pharmaceuticals.

Effects on aquatic life are a major concern in disposal of pharmaceuticals. A wide range of pharmaceuticals has been discovered in fresh and marine waters globally, and even in small quantities some of these compounds have the potential to cause harm to aquatic life.

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, which results in release of toxic pollutants into the air. Inefficient and insecure sorting and disposal may allow drugs beyond their expiry date to be diverted for resale to the general public.

Potentially infectious wastes: Improper training, handling, storage and disposal of the waste generated in health care facilities or activities can spread disease through several mechanisms. Transmission of disease through infectious waste is the greatest and most immediate threat from healthcare waste. If

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 15 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, by being inhaled into the lungs, being swallowed, or being transmitted by a vector organism.

Those 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, substance abusers and those who knowingly or unknowingly use “recycled” contaminated syringes and needles.

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, substance abusers and others who handle sharps have become infected with HIV and/or 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 before being disposed of, they can create and extend epidemics. The absence of proper sterilization procedures is believed to have increased the severity and size of cholera epidemics in Africa during the last decade.

3.2: HEALTHCARE WORKER/DELIVERY AGENT TRAINING; HEALTHCARE WORKFORCE

STRENGTHENING AND DEVELOPMENT

Constituent Activities. This intervention category consists of:

1. Training/supportive supervision activities focused on:

a. HIV/AID Support, including counseling and rapid HIV/AIDS testing, prevention of mother-to-child transmission (PMTCT) and Voluntary Medical Male Circumcision (VMMC); screening, testing, and treatment;

b. PEPFAR, Voluntary Counseling & treatment (VCT)

c. TB and multi-drug resistant tuberculosis (MDRTB), including training, screening, testing, and treatment; sputum transfer programs; and technical assistance in provision of clinical care in TB service settings, including examinations, clinical monitoring, and related laboratory services

d. Maternal and Child Health, including family planning, antenatal care (ANC), post-rape care;

nutrition

e. Malaria (PMI – Malaria Operations Plan)

f. Additional support for Palliative care training (e.g., social and material support, such as counseling in nutrition, legal aid, and housing), STI screening, prevention, and treatment services; other immunization and vaccination services (e.g., for Human Papilloma Virus, Pentavalente, and Pneumococcal)

g. Orphans and Vulnerable Children and Gender-Based Violence: activities include technical assistance, community mobilization, capacity strengthening of local nongovernmental organizations, and advocacy

Note re: Facility Rehabilitation & Equipment and Supplies Procurement Associated with Training:

Small-scale facility rehabilitation associated with training is covered under the construction section (Section 3.5) and subject to the relevant conditions described therein. Procurement of equipment associated with training is covered under the procurement section of the USAID/Mozambique Health Systems Strengthening IEE and subject to the relevant conditions described therein.

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 16

Potential Adverse Impacts & Considerations Regarding Recommended Determinations.

Training (including supportive supervision) is one of a class of activities under 22 CFR 216 eligible for categorical exclusion. However, training of health care providers is intended to improve and expand the delivery of and/or access to health care services. As described in section 3.1, the delivery of these services presents a set of potentially significant adverse environmental and health impacts, particularly waste-and bio-safety related.

Further, the purpose of the training activities and the development of training curricula are to influence the actions of healthcare providers/service delivery agents. Appropriate management of health care waste depends heavily on individual actions of these agents: e.g., is there consistent separation of sharps and “red bag” waste? Training therefore must, as appropriate, address proper handling, use and disposal of health care waste, including proper disposal of blood, sputum, and sharps.

Similarly, the district and regional health system managers who are the target of leadership development programs will likely influence the actions of healthcare providers and service delivery agents—as well as the physical condition and management of the health care facilities for which these leaders are responsible.

While USAID does not have control over the actions of health care providers/service delivery agents/managers post-training, it can—and it is needful to—assure that the curricula, training (including supportive supervision) and leadership programs fully and appropriately integrate sound management of health care waste.

Recommended Determinations. Following from the analysis above, the following determination is recommended for activities in this category.

Activity Recommended Determination

1. Training/supportive supervision focused on:

a. HIV/AID Support, including prevention of mother-to-child transmission (PMTCT) and Voluntary Medical

Male Circumcision

(VMMC); screening, testing, and treatment;

b. PEPFAR, Voluntary

Counseling & treatment

(VCT)

c. TB and MDRTB, including training, screening, testing, and treatment; sputum transfer programs

d. Maternal and Child Health, including family planning, antenatal care (ANC), post-

Negative determination with the following conditions:

Training, supervision, curricula development and other health care worker/workforce capacity building must address appropriate management practices concerning the proper handling, use, and disposal of medical waste, including blood, sputum, and sharps, when techniques or care situations being addressed would generate and require disposal of hazardous or highly hazardous waste (e.g. sharps, afterbirth from delivery, waste from screening for HIV or STDs, sputum samples for diagnosis of TB).

Where USAID-funded training activities directly generate HCW, USAID MUST assure appropriate management of this waste.

Note that this condition applies to activities targeting home care AND community health workers, not just those in clinics and health facilities.

Wherever relevant, appropriate disposal mechanisms in home-based and community-based situations that are cost effective and safe must be identified and appropriately incorporated in training, protocols, and guidelines. This includes training home care and community health workers to deliver positive messages about personal and household hygiene, sanitation, and proper disposal of condoms and other potentially harmful materials.

USAID/Mozambique Increased Coverage of High Impact Health and Nutrition Services IEE Dec 2014 pg 17 rape care; nutrition

e. Malaria (PMI – Malaria

Operations Plan),

f. Palliative care support, STI screening, prevention, and treatment services; other immunization and vaccination services (e.g., for Human Papilloma Virus, Pentavalente, and

Pneumococcal)

g. Orphans and Vulnerable

Children and Gender-Based

Violence

Additional conditions for tuberculosis activities. In addition to being subject to the conditions above:

Training/curricula/supervision in the area of TB diagnosis and care must address standards for diagnosis, including risk factors for TB, appropriate diagnostic testing for persons with symptoms, and appropriate clinical evaluation procedures.

Where USAID directly supports diagnostic testing, USAID must assure that the TB laboratories meet the reference standards established by WHO related to 1) codes of practice, 2) equipment, 3) laboratory design and facilities, 4) health surveillance, 5) training, and 6) waste handling. Depending on the specific tests conducted by a facility, additions and modifications to the WHO measures may be warranted for different levels of risk as described in WHO’s Tuberculosis Laboratory Biosafety Manual (2012 ed or later) (http://apps.who.int/iris/bitstream/10665/77949/1/9789241504638_eng.pdf

Mandatory references.

Training in TB diagnosis must conform to WHO guidance, specifically the Tuberculosis Laboratory Biosafety Manual (2012 ed or later). Available at:

http://apps.who.int/iris/bitstream/10665/77949/1/9789241504638_eng.pdf

Training in TB care, including diagnosis, treatment, and public health, must conform to the international standards articulated in the World Health Organization’s International Standards for Tuberculosis Care (http://www.who.int/tb/publications/ISTC_3rdEd.pdf?ua=1)

Conform to PMI Best Management Practices,…