UHCP INITIAL ENVIRONMENTAL EXAMINATION.pdf

Asia 23-204

PROJECT INITIAL ENVIRONMENTAL EXAMINATION (IEE)

PROGRAM DATA

Program/Activity Title: USAID/Philippines Universal Health Care Project

Development Objective: Improved Health Outcomes of Underserved and Vulnerable Filipinos Country/Region: Philippines/Asia Foreign Assistance Objective: Investing in People Program Area: 3.1 Health Program Elements: 3.1.1 HIV/AIDS

3.1.2 Tuberculosis

3.1.4 Global Health Security

3.1.6 Maternal and Child Health

3.1.7 Family Planning and Reproductive Health

Period Covered: 10/01/2023 - 12/31/2029 Life of Project Amount:

IEE Prepared By: Maria Teresa Carpio IEE Amendment (Y/N): No Current Date: May 25, 2023 Expiration Date: December 31, 2029

ENVIRONMENTAL ACTION RECOMMENDED:

Categorical Exclusion [ X ] Negative Determination with Conditions [ X ]

Positive Determination [ ] Deferral [ ]

CLIMATE RISK RATING

Low __X___ Medium __X__ High ____

SUMMARY OF FINDINGS:

Scope: This document provides the first review of the reasonably foreseeable effects on the environment and recommends threshold decisions and conditions for proposed activities under the USAID/Philippines Universal Health Care Project (UHCP). This IEE sets out activity-level procedures intended to ensure that potential environmental impacts are mitigated and conditions are implemented. This also documents the results of the project/activity level Climate Risk Management assessment process in accordance with USAID ADS 201mal. Approval of this document affirms the determinations per 22 CFR 216 and makes specified conditions mandatory obligations during program and activity implementation.

Outline and Recommended Threshold Decisions:

This document consists of the following sections:

I Purpose and Scope II Background and Description of the Health Project and Activities III Country and Environmental Information IV Analysis of Potential Environmental Impact V Recommended Threshold Decisions VI Climate Risk Management VII Monitoring and Implementation

This IEE recommends the threshold decisions summarized in the following table (NDC = Negative Determinations with Conditions):

Implementing Mechanism (IM) Categorical Exclusions

NDC

Health Systems Strengthening Activity ✔ ✔

Tuberculosis I: (Luzon and NCR) Activity ✔ ✔

Tuberculosis II (Visayas and Mindanao) Activity ✔ ✔

Family Planning and Reproductive Health Activity ✔ ✔

GHS Activities ✔ ✔

BARMM Resilience Activity ✔ ✔

Community Led Monitoring (CLM)/TB-HIV Activity ✔ ✔

HIV Activity ✔ ✔

Limitations: The Program will not undertake any activities determined to pose a significant effect on the environment under 22 CFR 216.2(d)(1). This IEE does not cover activities involving:

● indoor residual spraying of pesticides for malaria control;

● procurement, transport, use, storage, or disposal of pesticides or toxic materials;

● procurement or use and/or disposal of other hazardous/toxic materials for construction projects;

● procurement, use and/or disposal of equipment containing and/or generating low-level radioactive materials and wastes; and

● construction as defined in ADS 201maw & ADS 303maw.

Any of these actions would require an IEE amendment to be approved by the Mission Director and concurred by the Bureau Environmental Officer (BEO).

General Implementation and Monitoring Conditions: In addition to the specific conditions listed in Section V, the negative determinations recommended in this IEE are contingent on full implementation of a set of general monitoring and implementation requirements specified in Section VII. These include the following:

● briefings for implementing partners on environmental compliance responsibilities at the post award conference;

● development, integration, and implementation of an Environmental Mitigation and Monitoring Plan (EMMP), based on an environmental screening as needed, and Climate Risk Screening by each implementing partner;

● EMMPs for activities deemed moderate or high risk, will include appropriate measures to mitigate the impact of climate change, as discussed in Section VI;

● integration of environmental compliance responsibilities in prime and sub-contracts and grant agreements;

● assurance of sub-grantee and sub-contractor environmental compliance;

● environmental monitoring responsibility of the USAID/Philippines Office of Health;

and

● amending this IEE to reflect new or substantially modified activities

6/13/2023/s/

PROJECT INITIAL ENVIRONMENTAL EXAMINATION (IEE)

PROJECT/ACTIVITY DATA:

Activity Name: USAID/Philippines Universal Health Care Project

Country/Region: Philippines/Asia

Start Date: 10/01/2023 End Date: 12/31/2029

Life of Project Amount:

IEE Prepared by: Maria Teresa Carpio Date: 05/22/2023

Amendment: No

ENVIRONMENTAL ACTION RECOMMENDED:

Categorical Exclusion [ X ] Negative Determination with Conditions [ X ]

Positive Determination [ ] Deferral [ ]

CLIMATE RISK RATING

Low __X___ Medium __X__ High ____

I. Purpose and Scope

The purpose of this document, in accordance with Title 22, Code of Federal Regulations, Part 216 (22CFR216), is to provide a preliminary review of the reasonably foreseeable effects on the environment and recommend determinations, and as appropriate, conditions for the health activities detailed below. This IEE is a critical element of USAID’s mandatory environmental review and compliance process meant to achieve environmentally sound activity design and implementation. Potential environmental impacts should be addressed through formal environmental mitigation and monitoring plans (EMMPs) and/or Environmental Assessments (EAs), if needed.

This IEE documents the results of the project/activity level Climate Risk Management assessment process in accordance with USAID policy (specifically, ADS 201mal). Approval of this document affirms the determinations per 22 CFR 216 and makes specified conditions mandatory obligations during Universal Health Care Project implementation. The activities under review are recommended for the threshold decisions indicated in Table 1 below:

Table 1: USAID Universal Health Care Project Activities Covered in This IEE, 2013-2029

Implementing Mechanism (IM)

Projected Life of Project Amount

Projected Start and End Dates

Recommended Threshold

Determination

Health Systems Strengthening Activity

Oct 2023 – Sep

CE; NDC

Tuberculosis I: (Luzon and NCR)

CE; NDC

Tuberculosis II (Visayas and Mindanao)

CE; NDC

Family Planning and Adolescent Reproductive Health Activity

Oct 2024 – Sep

GHS Activities

Oct 2024 – Sep

CE; NDC

Community Led Monitoring Activity

Oct 2023 – Sep

CE; NDC

HIV Activity Oct 2023 – Sep

BARMM Resilience Activity

Notes: CE - Categorical Exclusion NDC - Negative Determination with Conditions

II. Background and Description of Activities

A. Background

The Philippines faces key challenges in its health sector that impede its ability to provide quality, accessible and equitable healthcare to the over 100 million Filipinos living in the country. Underserved populations, especially those from the lowest income quintiles, continue to suffer from a high prevalence of TB including MDR-TB, a concentrated HIV epidemic, high unmet need for family planning, high teenage pregnancy rate, and preventable maternal and newborn deaths due to limited adoption of healthy behaviors, inadequate service delivery, and vulnerable health systems. These challenges include global health crises and natural disasters and gaps in the continuum of care. These concerns are tied to capacities in national and local leadership and governance, health workforce development, public financial management, financial risk protection, logistics and supply chain management, information management system, delineation of responsibilities between national and local governments, and integration of public health programs at the primary care level.

Along with uncertainty in the new administration’s policy direction and organizational restructuring, and varying priorities of local government units, a key risk to UHCP implementation is emerging public health threats and disasters. The COVID-19 pandemic massively disrupted health systems, service delivery programming and health systems strengthening efforts as it shifted focus and resources away from regular programs and routine services and activities. Learning from the pandemic, UHCP includes a strong resilience strategy to better prepare the health system for shocks. The UHCP will support evidence-based planning and responses by establishing, strengthening, and utilizing robust data and strategic information systems. The Project will continue to scale up high impact interventions and innovations developed during the pandemic.

The UHCP will address challenges facing the country’s health sector by focusing on strengthening health systems, improving the quality of service delivery, and building or reinforcing positive social norms and behaviors. The Covid19 pandemic magnified the challenges in the health sector. The current health program undertook effective “catch up” measures that resulted in gains in family planning and TB programs, and in health systems strengthening efforts. The current program developed modules for and conducted capacity building in among others, procurement and supply chain management, continuous quality improvement, program management, monitoring and evaluation, gender and psychosocial assessment for adolescents, most of which were uploaded in the DOH Academy for on-demand access. Use of multiple messaging platforms doubled the reach of FP/ARH messages. Correlated to this, the number of adolescents who sought FP/ARH services increased. In the TB program, improved reporting from the private sector and intensified case finding record high TB case notification rate. The goal of the UHCP is to strengthen national and local health systems in line with the Philippine Development Plan 2023-2028 and the Universal Health Care Law with a focus on enhancing the quality and coverage of health services, effective local ownership and the management of health priorities. Project activities will implement focused health systems interventions to achieve key U.S. government objectives for TB, FP/ARH, HIV/AIDS, and GHS.

The UHCP will contribute to a sustained and coordinated multi-sectoral approach focusing on locally-led development and will pivot towards a more transformative model that seeks to address critical social determinants of health, including education, skills development, and employment, as well as animal and environmental health, to mitigate future impacts of macro-and microshocks to health systems. The UHCP will address key health objectives of the US and Philippines governments through a strategic composite of bilateral, regional, and global USAID implementing mechanisms. The GHS activity is a focused investment in strengthening the country’s resilience or capacity to prevent avoidable outbreaks; detect public health threats early; and respond rapidly and effectively using the One Health approach. The other health activities will integrate environmental and climate risk considerations in their core components where there are opportunities.

https://www.usaid.gov/biodiversity/stories/human-health-environment#:%7E:text=%E2%80%9COne%20Health%E2%80%9D%20is%20a%20collaborative,putting%20this%20approach%20into%20practice

B. Description of the Health Project and Activities

Project Purpose and Vision

The purpose of the Universal Health Care Project is to improve health outcomes of underserved and vulnerable Filipinos, in alignment with USG, USAID, and Philippine government objectives to achieve Universal Health Care. The UHCP aims to harmonize programming across health areas and achieve priority health outcomes for tuberculosis, family planning and adolescent reproductive health (FP/ARH), HIV/AIDS, global health security (GHS), health systems, and other health elements and threats. The UHCP will contribute to the following Philippines and USAID health goals:

● Reduce maternal and newborn deaths through healthy spacing of pregnancies;

● Reduce adolescent births;

● Reduce morbidity and mortality due to tuberculosis and other infectious diseases;

● Achieve 95-95-95 HIV targets;

● Achieve resilient health systems through strengthened primary health care; and

● Increase overall life expectancy and enhance quality of life for Filipinos.

The UHCP is aligned with the USAID/Philippines’ Country Development Cooperation Strategy (CDCS) for 2019-2024, which has as its goal to help ensure that the Philippines is a Well- Governed and More Self-Reliant Indo-Pacific Partner. The strategy includes Development Objective 1, “Democratic Governance Strengthened” with sub Intermediate Results (IR) “Local service delivery enhanced” and “Stakeholder participation in key local bodies expanded” under IR 1.4 “More Responsive Local Governance”. The CDCS also includes Development Objective 2, “Inclusive, Market-Driven Growth Expanded” with “Priority health outcomes improved” as a sub-IR to Intermediate Result (IR) 2.3: “Human Capital Development Improved”. As the Global Health Security activity commences, the UHCPnow also serves Development Objective 3, “Environmental and Community Resilience Enhanced”, and particularly IR 3.3, “Response to Transnational Threats Strengthened”. The UHCP contributes to IR 3.4, “Capacity to Mitigate Risks of and Respond to Disaster Strengthened”. The UHCP integrates priority adaptations identified during the 2022 CDCS Mid-Course Stocktaking exercise, namely, food security, climate resilience and anti-corruption efforts.

Sub-Purposes

The purpose of UHCP is Improved Health Outcomes of Underserved and Vulnerable Filipinos.

This will be achieved if health system performance and resilience is improved, if high quality and responsive health services are delivered, and if positive social norms and behaviors are adopted. The vision is that individuals, particularly underserved and vulnerable populations, will gain control of their own health, have continuous access to evidence-based information and affordable, quality services and commodities, and benefit from a more responsive and resilient health system.

This entails developing stronger partnerships with national and local government, private sector, and local organizations towards fortification and institutionalization of healthy norms, services, and health systems. For the underserved, it means engaging with a host of providers of information and services relevant to their age, social, and cultural mores, and health needs.

For service providers, it means adopting state-of-the-art approaches and technology to improve their effectiveness, reach, and service coverage. For systems strengthening, it means deeper engagement with the local actors and local systems that are crucial to continued achievement and sustainability of overall health outcomes.

Sub-purpose 1: Positive Social Norms and Behaviors Adopted

1.1 Improved individual adoption of healthy behaviors;

1.2 Improved community ownership and participation in healthy behavior;

1.3 Strengthened advocacy to demand quality health services and protection of individual rights and security; and

1.4 Expanded multi-sectoral partnerships.

Strengthening positive social norms and healthy behaviors will be achieved by providing information and activities, and developing new local partnerships that influence social norms and allow individuals to make informed choices about how to protect their health, sustain the practice of healthy behavior, and access health services when needed.

Sub-purpose 2: Responsive and High Quality Services Delivered

2.1 Integrated quality preventive, clinical, and laboratory services;

2.2 Build human resources for health skills and competencies;

2.3 Innovation, research and development; and

2.4 Improved quality of health services through patient-centered and inclusive approaches.

The UHCP will focus on improving the quality of primary health care services using patient-centered approaches to diagnose, provide care and treatment, and mentor health care providers. The UHCP will identify, develop, and implement innovations to improve the quality of health services.

Sub-purpose 3: Health Systems Resilience Improved

3.1 Strengthened health leadership and governance;

3.2 Improved public financial management and risk protection for the poor;

3.3 Fit-for-purpose human resources for health with skills and competence;

3.4 Improved public sector supply chain management; and

3.5 Functional health information system for timely decision-making.

Under this sub-purpose, health system functions – health workforce development, provision of commodities, governance, and financial risk planning and budgeting – that are considered critical by the DOH, USAID and other stakeholders will be fortified, institutionalized, and sustained.

Activities covered in this IEE by sub-purpose are listed in Table 2 while illustrative activities and recommended threshold determination by sub-purpose are listed in Table 3.

Table 2: Health Activities by Sub-Purposes 2023-2029

Implementing Mechanism (IM)

Pursues Sub- Purpose

Recommended Threshold Decision

1 2 3

Health Systems Strengthening Activity ✔ ✔ ✔ CE*; NDC**

Tuberculosis I: (Luzon and NCR) ✔ ✔ ✔ CE; NDC

Tuberculosis II (Visayas and Mindanao) ✔ ✔ ✔ CE; NDC

Family Planning / Adolescent Reproductive Health ✔ ✔ ✔ CE; NDC

GHS Activities ✔ ✔ ✔ CE; NDC

Community Led Monitoring / TB-HIV Activity ✔ ✔ ✔ CE; NDC

HIV Activity ✔ ✔ ✔ CE; NDC

*Categorical Exclusion **Negative Determination with Condition

The USAID UHCP’s geographic focus will be based on review and analysis of province and city-level data on a host of critical indicators including but not limited to health outcomes, disease burden, performance metrics, and contextual information to determine the geographic site-level support necessary for achieving maximum health outcomes among the most vulnerable populations, while also optimizing resources. Site selection will also be informed by USG priorities and inputs from the host government, the private sector, and civil society. Final site determination will be a key milestone of the co-creation process. Within the selected sites, resilience strengthening efforts will be pronounced in provinces or cities/ municipalities that are more vulnerable to the effects of climate change especially in localities with receptive leadership.

Table 3: Planned Health Actions by Sub-Purpose and Recommended Threshold Decision

Goal: Improved Health Outcomes of Underserved and Vulnerable Filipinos

Outcome 1: Positive Social Norms and Behaviors Adapted

Outcome 2: Responsive and High-Quality Services Delivered

Outcome 3: Health Systems Resilience Improved

Illustrative Activities:

● Conducting research and consultation in locations of marginalized and vulnerable populations;

● Developing social and behavior change communication materials;

● Building capacity of health service providers, educators, LGUs, CSOs, and other stakeholders in communication and advocacy;

● Mentoring, monitoring, and evaluation of healthy behaviors among HSPs, educators, peer navigators, and youth leaders;

● Organizing and mobilizing information, education, and service outreach and caravans

- likely NDC;

● Conducting seminars and webinars for information, education, and capacity building;

● Positive target client engagement towards strengthening their agency and self-

Illustrative Activities:

● Strengthening the clinical and communication skills of health service providers for client-centered care -

NDC;

● Building the referral system that facilitates improved navigation for individuals and communities through a continuum of healthcare from primary to tertiary facilities including outreach, in both physical or virtual venues;

● Capacity building for outreach health service delivery - likely NDC;

● Developing or strengthening client feedback mechanisms as part of continuing quality improvement;

● Identifying motivations for and setting up arrangements to ensure delivery of incentives to improve and sustain quality health service performance and outcomes.

Illustrative Activities:

● Strengthening supply chain management systems including prepositioning for emergency surge requirements - NDC;

● Facilitating digital transformation of health information systems that consider interoperability with manual and other electronic systems - likely

NDC;

● Establishing reliable and sustainable health human resource management and development arrangements that include local community engagement;

● Establishing or strengthening community monitoring systems towards systematic collection of relevant data;

● Facilitating functioning of provincial or city health financing system/s;

● Integrating absorptive, adaptive, and transformative capacity building to strengthen resilience of local health systems likely NDC.

efficacy.

Recommended Threshold Decision: CatEx, NDC

Recommended Threshold Decision: CatEx, NDC

Recommended Threshold Decision: CatEx, NDC

Based on 22 CFR 216 provisions discussed in Section V below, specific illustrative activities are recommended or likely to be recommended for Negative Determination with Conditions classification. The rest are recommended for Categorical Exclusion threshold determination.

III Country and Environmental Information

The Government of the Philippines (GPH) is signatory to several international environmental agreements such as the 2030 Agenda for Sustainable Development, the Rio Declaration on Environment and Development, the United Nations Framework Convention on Climate Change, https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf https://www.un.org/en/development/desa/population/migration/generalassembly/docs/globalcompact/A_CONF.151_26_Vol.I_Declaration.pdf https://www.un.org/en/development/desa/population/migration/generalassembly/docs/globalcompact/A_CONF.151_26_Vol.I_Declaration.pdf https://unfccc.int/resource/docs/convkp/conveng.pdf the Hyogo Framework of Action and its successor Sendai Framework for Disaster Risk Reduction 2015-2030 1987 Montreal Protocol, the Basel Convention, and the Stockholm Convention. As signatory to these agreements, the Philippines commits itself to the principles of sustainable development, climate change adaptation, disaster risk reduction and management, and protection of human health and the environment. International commitments are supported by national efforts to enact environmental laws and policies. Foremost of these is the Climate Change Act (CCA) of 2009, which promotes the principles of subsidiarity among local government units (LGUs) to serve as frontline agencies to address climate change at the local level and multi-stakeholder participation and partnerships.

In the Philippines, the national-level strategy to address issues related to environmental health is the National Environmental Health Action Plan or NEHAP 2017-2022, which is currently being updated. The NEHAP is developed and implemented by the InterAgency Committee on Environmental Health, led by the DOH and DENR, along with nine other participating agencies and nongovernmental stakeholders. The current NEHAP was updated in alignment with the 2030 Sustainable Development Goals, and is organized by the following thematic areas: Water Supply, Sanitation and Health, Air Quality and Health, Occupational Safety and Health, Chemical Safety and Health, Food Safety and Health, Solid Waste Management and Health, and Climate Change and Health. For each thematic area, the NEHAP provides a situational analysis, strategies, and activities to be undertaken by the participating agencies and stakeholders, and indicators for monitoring and evaluation. The priority focus areas across sectors are policies and regulatory framework, data and information, national sector programs, and capacity building.

Several Philippine statutes provide guidelines on proper waste management. The 1965 Republic Act (RA) 4226 or the Hospital Licensure Act, as enunciated in the Department of Health’s AO 1965-01 Rules and Regulations Implementing RA 4226, provides that healthcare facilities shall provide for the “maintenance of sanitary standards, including approved water supply and sewage disposal systems throughout hospital buildings and premises for the purpose of ensuring cleanliness and as a protection against the spread of infectious and contagious diseases”.

Republic Act (RA) 6969 or the Toxic Substances and Hazardous and Nuclear Waste Act of 1990 provides guidance on managing hazardous and infectious wastes in such a manner as not to cause or potentially cause pollution; danger to public health, welfare and safety; harm to animals, birds, wildlife, fish or other aquatic life, plants, and vegetation; and limitation in the beneficial use of a segment of the environment. RA 6969 further provides that the waste generator shall be responsible for the proper management and disposal of the hazardous waste, and shall bear the costs for the proper storage, treatment and disposal of their hazardous wastes. Health care facilities as generators of health care waste have these responsibilities.

Among the most relevant policies and regulations governing health care waste management are the joint issuance of the Department of Environment and Natural Resources (DENR) and the https://www.undrr.org/publication/hyogo-framework-action-2005-2015-building-resilience-nations-and-communities-disasters https://www.preventionweb.net/files/43291_sendaiframeworkfordrren.pdf?_gl=1*o6zov9*_ga*NzMxMjcyMDI2LjE2ODM4Njg5MDM.*_ga_D8G5WXP6YM*MTY4Mzg2ODkwMy4xLjEuMTY4Mzg2OTAyMi4wLjAuMA..

https://www.preventionweb.net/files/43291_sendaiframeworkfordrren.pdf?_gl=1*o6zov9*_ga*NzMxMjcyMDI2LjE2ODM4Njg5MDM.*_ga_D8G5WXP6YM*MTY4Mzg2ODkwMy4xLjEuMTY4Mzg2OTAyMi4wLjAuMA..

https://doh.gov.ph/sites/default/files/publications/nehap-2017-2022.pdf https://elibrary.judiciary.gov.ph/thebookshelf/showdocs/2/22203#:%7E:text=%5B%20REPUBLIC%20ACT%20NO.%204226%2C%20June%2019%2C%201965,MEDICAL%20SERVICES%20TO%20SERVE%20AS%20THE%20LICENSING%20AGENCY.

https://elibrary.judiciary.gov.ph/thebookshelf/showdocs/2/22203#:%7E:text=%5B%20REPUBLIC%20ACT%20NO.%204226%2C%20June%2019%2C%201965,MEDICAL%20SERVICES%20TO%20SERVE%20AS%20THE%20LICENSING%20AGENCY.

http://www.gov.ph/1990/10/26/republic-act-no-6969/

Department of Health (DOH) governing health care waste management and the Department of Health Healthcare Waste Management Manual. The DOH-DENR Joint Administrative Order No.

02 series of 2005, Policies and Guidelines on Effective and Proper Handling, Collection, Transport, Treatment, Storage and Disposal of Healthcare Wastes7 , aims to: (a) provide guidelines to generators, transporters and operators/owners on proper handling, collection, transport, storage, treatment and disposal of healthcare waste; (b) clarify the jurisdiction, authority and responsibility of the DENR and DOH with regard to healthcare waste management; and (c) harmonize the efforts of the DENR and the DOH on healthcare waste management. The DOH Healthcare Waste Management Manual 2020 provides guidelines on the safe management, i.e. segregation, collection, handling, storage, treatment, and disposal of waste generated from healthcare activities in the country. It is based on the requirements of all Philippine laws and regulations governing HCWM.

Requirements for DOH licensing, a requisite for PhilHealth accreditation, include compliance of health care facilities with minimum standards for environmental protection, proper waste disposal and infection prevention. Some LGUs have their own local regulations on waste disposal. However LGUs do not conduct compliance monitoring uniformly or regularly. In general, Government of the Philippines guidelines are consistent with USAID guidance on environmental compliance regarding matters such as health care waste management.

IV Analysis of Potential Environmental Impact

Per 22 CFR 216, Missions should identify, assess, avoid, and mitigate, as appropriate, the potential environmental impacts of all USAID-funded activities. The Office of Health conducted an Environmental Analysis to ensure that activity design and implementation are environmentally- sound and that corresponding mitigating measures are incorporated in the design and approval of the project and of each health activity. The analysis, based on USAID’s environmental procedures, will inform the 2024-2029 UHCP Initial Environmental Examination.

The IEE is a preliminary review of the potential effects of USAID interventions on the environment and recommends determinations and, as appropriate, conditions for these activities. The Agency-cleared P/IEE is requisite to any funds obligation. No health activity determined to have a threshold determination of negative with conditions will commence unless the IP has an A/COR-approved EMMP, a copy of which is sent to the MEO/CIL.

Planned Health activities will focus on quality service delivery, social and behavior change communication, and health systems strengthening in the areas of FP/ARH, TB, HIV/AIDS, global health security (GHS), health systems, and other health elements and threats.. The UHCP will focus on strengthening local health systems to be especially responsive to vulnerable and underserved populations.

While development activities are intended to provide benefits for targeted recipients, when managed ineffectively they may cause adverse impacts that can offset or eliminate these https://www.medbox.org/document/health-care-waste-management-manual-fourth-edition#GO http://www.searo.who.int/LinkFiles/publications_PracticalguidelinSEAROpub-41.pdf https://www.usaid.gov/sites/default/files/2022-05/FINAL_HCW_SEG_508_12.02.19.pdf intended benefits. Impacts can be direct, indirect, or cumulative. They can also be beneficial or negative. The 2019 USAID Sectoral Environmental Guidelines Healthcare Waste provides additional information on the potential impacts of Healthcare Waste (HCW).

HCW generation is inevitable in the provision of health services. If not managed appropriately, HCW can have hazardous impacts on the environment and the general public. Transmission of disease through infectious waste is the greatest and most immediate threat from HCW. If waste is not treated in a way that destroys the pathogenic organisms, dangerous quantities of microscopic disease-causing agents such as 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.

Chemical and pharmaceutical waste, especially in large quantities, can be a threat to the environment and human health. Since hazardous chemical waste may be toxic, corrosive, flammable, reactive and/or explosive, they can harm people who touch, inhale or are in close proximity to them. If burned, they may explode or produce toxic fumes. Some pharmaceuticals are toxic as well.

V Recommended Threshold Decisions

Similar to the typical USAID healthcare interventions, UHCP interventions include:

● Facilitating provision of pharmaceuticals or health commodities (e.g., anti-retroviral medication and/or family planning supplies);

● Support for the direct provision of health services (e.g., vaccinations, medical evaluations, and/or maternal and child healthcare);

● Capacity building for healthcare providers (e.g., nurses and/or doctors) and healthcare education;

● Capacity building for healthcare institutions (e.g., NGOs, clinics, and/or hospitals); and

● Capacity building for healthcare delivery and management systems above the facility level, which may engage host-country government institutions and agencies at the district, regional, or national levels, as well as private, NGO, and faith-based healthcare networks.

Health activities involving any of the above classes of actions shall integrate measures to avoid or mitigate potential adverse environmental impacts. The USAID sectoral environmental guidelines on health facilities (2014) and on health care waste (2019) provide a comprehensive list of conditions and mitigation measures that can be integrated in the design or adapted in the implementation of different health activities. Activities involving pharmaceuticals will be consistent with the US Environmental Protection Agency guidance on hazardous pharmaceutical wastes managements and the Health Care Waste Management Manual, 4th edition. The guidelines also provide helpful references in formulating EMMPs, which are a https://www.usaid.gov/sites/default/files/2022-05/FINAL_HCW_SEG_508_12.02.19.pdf https://www.usaid.gov/sites/default/files/2022-05/FINAL_HCW_SEG_508_12.02.19.pdf https://www.usaid.gov/sites/default/files/2022-05/FINAL_HCW_SEG_508_12.02.19.pdf https://www.epa.gov/hwgenerators/management-hazardous-waste-pharmaceuticals https://www.epa.gov/hwgenerators/management-hazardous-waste-pharmaceuticals https://www.medbox.org/pdf/6110e504321b6908df0163e4 https://www.medbox.org/pdf/6110e504321b6908df0163e4 vehicle for translating IEE conditions and mitigation measures into specific, implementable, and verifiable actions.

The Health Care activities fall under Categorical Exclusion (CE) and/or Negative Determination with Conditions (NDC). Categorically excluded actions do not individually or cumulatively have a significant effect on human health or the human environment. Actions determined as NDC are assessed to have the potential for directly or indirectly affecting the environment, and thus are required to have an approved Environmental Mitigation and Monitoring Plan (v2022). When Implemented with the specified conditions, NDC actions are likely to have insignificant adverse effects on the environment.

A. Justification for Categorical Exclusion Request

Implementing mechanisms covered in this IEE for which all the actions are recommended for Categorical Exclusion are listed in Table 5. The actions under review that justify Categorical Exclusion are detailed in Table 3. All activities under Table 5 have actions with Categorical Exclusion threshold determination.

In general, they are technical assistance and capacity-building activities that involve education, training, workshops, research, studies and transfer of information. All planned actions in the above health implementing mechanisms and certain actions in all implementing mechanisms covered in this IEE do not have foreseeable direct adverse environmental impacts. Specifically, pursuant to 22 CFR 216.2 (c)(1) and (2), the activities that fall into the following classes of action are recommended for Categorical Exclusion:

● 22 CFR 216.2 (c)(2)(i): education, technical assistance, or training programs except to the extent such programs include activities directly affecting the environment (such as construction of facilities, etc.),

● controlled experimentation exclusively for the purpose of research and field evaluation which are confined to small areas and carefully monitored per 22 CFR 216.2 (c)(2)ii;

● analyses, studies, academic or research workshops and meetings per 22 CFR 216.2 (c)(2)iii;

● document and information transfers per 22 CFR 216.2(c)(2)v;

● programs involving nutrition, health care or population and family planning services except to the extent designed to include activities directly affecting the environment (such as construction of facilities, water supply systems, waste water treatment and treatment of water in the households), per 22 CFR 216.2(c)(2)viii; and

● studies, projects or programs intended to develop the capability of recipient countries to engage in development planning, except to the extent designed to result in activities directly affecting the environment (such as construction of facilities, etc.) 22 CFR 216.2(c)(2)xiv.

B. Negative Determination with Conditions https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.usaid.gov%2Fsites%2Fdefault%2Ffiles%2F2022-12%2FEMMP_English_Version_3.2_June_2022.docx&wdOrigin=BROWSELINK

Implementing mechanisms in Table 5 have actions that are recommended for a threshold determination (RTD) of Negative Determination with Conditions per 22 CFR 216.

Table 5: Health Activities with Negative Determination with Conditions RTD

HSS. To improve access to quality public health and primary care services (TB, FP/ARH, and HIV), and to enhance capacity to prevent, detect, and respond to emerging and re-emerging health threats, this activity will focus on strengthening functional health system components particularly in leadership and governance, financing, supply chain and logistics, human resources for health, service delivery organization, emergency preparedness, and health information systems.

TB 1. To reduce national tuberculosis mortality and morbidity with a focus on Luzon and NCR, this Activity will work to reduce out of pocket expenditures and increase tuberculosis notification, treatment success and quality of services while addressing socio-economic determinants of TB. It will support the DOH in developing new policies and standards to facilitate implementation of the National TB Strategic Plan and roadmaps.

TB 2. With the same goal as TB1 but covering Visayas and Mindanao except BARMM, this Activity will foster sustainability in local TB programs and partner with local stakeholders to implement local solutions that empower and strengthen accountability. It will leverage additional resources with matching grants and support localization of national policies to achieve TB goals in these island clusters. Eligibility for this activity will be restricted to a local organization.

FP/ARH. To contribute to improving the health and quality of life and reducing morbidity and mortality among mothers, adolescents, children and newborns, this activity will strengthen healthy behavior among youth, women, and men, and fortify the quality of family planning and adolescent health services in areas with high unmet need for family planning and high teenage pregnancies.

HIV - The HIV activity is designed to break through remaining, persistent barriers to the 95- 95-95 goals and promote sustainable management of national HIV programs. In response to USAID Mission and country needs, the HIV activity will deliver efficient, affordable, results-based technical assistance and direct service delivery tailored to context and epidemiology that is effective in surging, scaling, and sustaining HIV services and systems for long-term epidemic control.

The Global Health Security (GHS) activity aims to strengthen the country’s capacity to prevent avoidable outbreaks; detect threats early; and respond rapidly and effectively when outbreaks occur. The activity will harness the experience and the systems built to support the covid response and utilize the One Health approach recognizing that the well-being of humans, animals, and the environment are inextricably linked.

The BARMM Resilience activity, to be implemented by a PIO, will work with the integrated HSS Activity to support the key and cross-cutting reforms for governance, financing, supply chain and logistics, human resources for health, and health information in selected province- and city-wide health systems to provide a more conducive setting to implement priority programs like GHSA, TB, FP, among others.

These UHCP activities involve actions that may generate healthcare waste, or in other ways, directly or indirectly affect the community and the environment adversely, such as:

1. Procurement, use, storage, management and disposal of public health commodities used for delivery of services in family planning; screening, treatment, and prevention of tuberculosis and HIV/AIDS; and maternal and neonatal health, such as the following:

● medical supplies, pharmaceuticals, including over-the-counter and prescription drugs and medications; and

● catheters, bandages, sutures, syringes, scalpels, sharps and other health supplies.

2. Capacity building for healthcare providers (e.g., nurses and/or doctors) and healthcare education, for healthcare institutions (e.g., NGOs, clinics, and/or hospitals), and for healthcare delivery and management systems above the facility level, which may engage host-country government institutions and agencies at the district, regional, or national levels, as well as private, NGO, and faith-based healthcare networks in health facilities and communities that directly or indirectly result in the generation, storage, handling, and disposal of hazardous medical waste or in techniques that have a direct or indirect environmental impact such as:

● training on provision or administration of family planning methods, and TB or HIV/AIDS screening;

● support for deployment of itinerant teams that provide family planning services particularly short, long-acting, and permanent methods;

● training and application of essential intrapartum and neonatal care, including neonatal resuscitation, emergency obstetric care, and essential newborn care, as necessary; and

● training of health care workers as part of strategies to intensify TB case finding and treatment in indigenous populations, plantation and mining populations, geographically isolated and depressed areas, congregate settings of the urban poor, and population groups at risk for TB or multi-drug resistant TB (MDR-TB).

3. Improper use of equipment may reduce its useful life and the disposal of electronic waste might negatively impact the environment if not properly handled. Health activities may involve the use and disposal of healthcare equipment such as:

● general medical equipment, infant monitors, breastmilk pumps, and other equipment and fixtures used for FP/MCH service delivery;

● cartridges to be used with GeneXpert, the technology for rapid diagnosis of drug resistant TB; and

● minor laboratory equipment support for expanding access to TB diagnostic services.

4. Improper use of electric and electronic equipment may reduce its useful life and the disposal of electronic waste might negatively impact the environment if not properly handled. Health activities may involve limited procurement and distribution of small electric and electronic equipment, such as cellular phones, netbooks and tablets, in support of the following:

● health services monitoring, logistics management, health information systems management; and other related purposes;

● strengthening TB and HIV/AIDS logistics management, tracking and scaling up HIV screening, or TB case-holding and treatment at the community level to reduce rates of drop-outs of patients and other related purposes

The following are specific conditions to mitigate the potential negative impacts discussed in Section IV.

Conditions for (a) the procurement, use, storage, management, and disposal of public health commodities used for delivery of services; and (b) training in health facilities and in communities that directly or indirectly result in the generation, storage, handling, and disposal of hazardous medical waste, or in techniques that have a direct or indirect environmental impact:

USAID must work with implementing partners to ensure that:

● when training professionals or community health workers in service delivery procedures that result in the generation and disposal of potentially hazardous medical waste, the curricula should cover best management practices concerning the proper handling, use, and disposal of medical waste, as applicable, and that it is consistent with current DOH protocols; and

● the medical facilities have procedures in place to properly handle, label, treat, store, transport, and properly dispose of blood, placenta, sharp,s and other medical waste such as used sputum cups, slides, applicator sticks, syringes, and cartridges for GeneXpert as well as sputum specimens, based on standards of DOH and USAID or based on guidelines developed from these standards.

At the start of each activity, the implementing partner, in consultation with the Assistance Officer’s Representative (AOR) or Contracting Officer’s Representative (COR) will formulate an Environmental Mitigation and Monitoring Plan. The IP will validate the plan’s consistency with DOH and USAID guidelines as well as with internationally accepted standards for medical waste disposal. As appropriate, the implementing partner will work with facility, local, regional, and/or national officials to implement and apply appropriate best management practices which incorporate appropriate health and safety measures and environmental safeguards, including proper disposal of medical waste. The management of potential health and environmental hazards from health service delivery and health systems management may include ensuring LGUs are aware of and adhere to local standards of medical waste disposal. Implementing partners may require selected medical facilities to complete a Healthcare Waste Management Minimum Program Checklist and Action Plan (Annex 1) as part of monitoring.

Conditions on the use/disposal of medical equipment and supplies:

Implementing partner(s) should ensure and provide the AOR/COR with evidence that equipment is procured from certified retailers and include environmental safety and quality certificates that conform to national and/or international standards. The recipient of the equipment should be provided with information on the proper use of and instructions on proper disposal of electronic waste. The recipient should also be provided with a list of Government of the Philippines-accredited recyclers for proper disposal of the equipment after its useful life.

Conditions on the use and disposal of small electric and electronic equipment, such as cellular phones, netbooks and tablets:

No special mitigation measures are needed. Normal good practices will be used. The proposed action is that the implementer should provide evidence that equipment is procured from certified retailers and include environmental safety and quality certificates that conform to national and/or international standards. The recipient of the equipment should follow all applicable national and international laws to ensure that it is used in an environmentally sound and safe manner. Equipment should be properly disposed of (when applicable) at the end of its useful life in a manner consistent with best management practices according to USG, European Union, or equivalent standards acceptable to USAID.

Conditions and best practices for general classes of activities involving healthcare waste:

● All activities shall be conducted following principles for environmentally sound development, as provided in the 2019 USAID Sector Environmental Guidelines Healthcare Waste.

● An Environmental Mitigation and Monitoring Plan shall be developed that includes the principles of the guidelines.

● Each activity that has healthcare waste should have a sound healthcare waste management plan and system to minimize adverse health and environmental impacts caused by their wastes. A program to manage healthcare waste includes the minimum elements: (1) written plan; (2) clear responsibilities; (3) written internal rules; (4) staff training; (5) protective clothing; (6) good hygiene practices; (7) vaccinated workers; (8) designated storage locations; (9) waste minimization; (10) waste segregation; (11) waste treatment; (12) final disposal site; and (13) periodic reviews. The format and guidance of this report shall follow the Healthcare Waste Program Checklist provided as Annex 3 in the 2019 USAID Sector Environmental Guidelines Healthcare Waste.

● With activities involving health commodities, the implementing partner should have a written plan to ensure appropriate procurement, storage, management and/or disposal of public health commodities, including pharmaceutical drugs and nutritional supplements such as established adequate procedures and capacities in place to properly manage and dispose of such commodities.

Conditions and best practices for general classes of activities involving Healthcare Facilities:

● All activities shall be conducted following the principles for environmentally sound development, as provided in the USAID Sector Environmental Guidelines – Health Facilities.

● Plan for health care waste management.

● Ensure sufficient water supply and sanitary management capacity.

● Support provided to activities that include healthcare waste should have a sound healthcare waste management plan and system to minimize adverse health and environmental impacts caused by their waste, following healthcare waste management guidelines.

● An EnvironmentalMitigation and Monitoring Plan shall be developed that includes the principles of the aforementioned guidelines, following this template.

VI. Climate Risks and Climate Risk Management

Pursuant to Executive Order 13677 on Climate Resilient International Development, as defined in the ADS 201 Mandatory Reference, USAID must factor climate resilience in development programs, assessing and addressing climate risks, as appropriate. The design team used the climate risk-screening tool and existing climate change vulnerability assessments and risk analyses, previously conducted by USAID, other donors, the Philippine government and local institutions.

Climate change in the Philippines is expected to cause warmer temperatures, shifting rainfall patterns, stronger droughts, and intense storms that will result in more flooding, landslides, as well as sea level rise in coastal areas and in many poorly planned urban areas. Climate events can have massive consequences such as deaths from extreme weather events, cardiovascular and respiratory diseases, infectious diseases, and malnutrition while undermining water and food supplies, infrastructure, health systems, and social protection systems14.

Climate events, disasters and other disruptions aggravate weaknesses in the health system. The January 2020 eruption of Taal Volcano, while arguably not a climate event but a disaster nonetheless, revealed the chronic TB drug stockout in many LGUs in the affected region, the insufficiency of facilities for cold chain management (of GeneXpert cartridges), and the non-existence of prepositioned medical supplies,…