Initial Environmental Examination (Iee)

INITIAL ENVIRONMENTAL EXAMINATION (IEE)

PROJECT/ACTIVITY DATA:

Activity Name:Cambodia Health Project, 2017-2023

Country/region: Cambodia

Start Date: 5/31/2017 End Date: 6/30/2023

Life of Project Amount ($): USD $164,621,012

IEE Prepared by: Lisa K. Walker Date: 9/27/2018

Amendment: no

ENVIRONMENTAL ACTION RECOMMENDED: (Place X where applicable)

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

Positive Determination:[ ] Deferral: [ ]

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, as well as recommended Threshold Decisions, for the activities detailed below. This document provides a brief statement of the factual basis for Threshold Decisions as to whether an Environmental Assessment or an Environmental Impact Statement is required for the activities managed under the scope of this document.

The activities detailed in this IEE include both those that will continue under existing implementing mechanisms and those that will be newly designed and procured. This IEE replaces and supersedes the previous umbrella IEE (ASIA 14-141), approved August 28, 2014 and found at:

Implementing Mechanisms covered in this IEE include:

Activity Name / Total budget amount in Health PAD / Dates / Recommended Threshold Decisions
Support to the Social Health Protection Project in Cambodia / $400,000 / Mar 6, 2016 - Mar 5, 2019 / Categorical Exclusion
Health Information Policy and Advocacy Program (HIPA) / $1,500,000 / Mar 6, 2014 – June 5, 2018 / Categorical Exclusion
Social Health Protection Project (SHP) / $3,900,000 / December 26, 2013 – December 25, 2018 / Categorical Exclusion
HIV Innovate and Evaluate Project / $400,000 / August 30, 2013 – March 1, 2018 / Categorical Exclusion
HIV Flagship / $4,000,000 / November 14, 2012 - November 13, 2017 / Categorical Exclusion
Negative Determination with Conditions
Empowering Communities for Health Program (ECH) / $2,861,382 / October 1, 2014 – March 30, 2018 / Categorical Exclusion
Quality Health Services / $4,233,828 / January 17, 2014 - January 16, 2019 / Categorical Exclusion
Negative Determination with Conditions
Cambodia Malaria Elimination Project (CMEP) / $16,543,857 / October 26, 2016 - October 25, 2021 / Categorical Exclusion
Negative Determination with Conditions
Quality Improvement / $25,323,326 / Planned January 2018 – December 2022 / Categorical Exclusion
Social and Behavior Change (SBC) / $11,463,105 / Planned March 2018 – March 2023 / Categorical Exclusion
Subtotal of total budget of mechanisms covered in this IEE / $70,625,498
Subtotal cost of mechanisms not covered by this IEE (because they are field support or centrally-funded mechanisms covered under separate IEEs) / $69,901,457
Costs for Program administration and oversight (A&O) and
Program development and learning (PD&L) / $24,094,057
Budget total for entire Cambodia Health Project, 2017-2023 / $164,621,012

The activities under review are recommended for the threshold decisions indicated above in the table and the “Environmental Action Recommended” section.

1.0 Description of Activities

The Office of Public Health and Education will build on USAID/Cambodia’s previous experiences and comparative advantages in health and child protection programming, and the new Project will fall within its manageable interest. The project will support the Royal Government of Cambodia’s (RGC) Third Health Strategic Plan (HSP3) goals.

Where feasible, the project team will take an integrated approach to improving health status rather than targeted interventions for specific disease entities, and will work at a more strategic level, instead of the current focus on service delivery. Many of the interventions will be of a policy nature (such as regulation, national policies, health and child protection), and work done at the national level will have broad impact across the country. Sub-national activities align with the National Committee for Sub-national Democratic Development’s three year Implementation Plan, Phase 2,and will include capacity strengthening in provinces, districts, and communes to ensure quality of care and implementation of activities; to better address the technical and financial aspects of Decentralization and De-concentration as they relate to health and child protection; and to better serve communities and consumers of health and social services and products, particularly the poor, near poor, and vulnerable populations.

The purpose of the Health Project is: Cambodian people seek and receive quality health care and social services with decreased financial hardship through more sustainable systems. To attain this purpose, the Project will improve health and child protection behaviors, improve health financing and social protection, and improve the quality of public and private health and social services.

Sub-Purpose 1: Improved health and child protection behaviors

Although Cambodia has done well in improving life expectancy and health indicators, including attaining its established Millennium Development Goals ahead of schedule, there are important challenges in bringing about the change envisioned in this Project. Despite the appearance of a high level of health awareness, there are notable discrepancies between what people know, what they do, and the treatment they seek — both in the public and the private sectors. Cambodians frequently seek treatment from poorly trained or unqualified providers and can receive ineffective and harmful health care, advice, services, and commodities, with little or no consumer rights protection. Delays in seeking treatment from a qualified health care provider can result in serious morbidity or mortality.

Illustrative Project interventions include:

• Strengthening local capacity for evidence-based advocacy by building skills and addressing biases that present barriers to health care and social services;
• Developing and testing methods and tools to change provider and caregiver behavior;
• Applying innovative approaches for models of influences for positive health and social behavior changes, especially to reach youth, populations at risk, and underserved populations such as migrants and Lesbian, Gay, Bisexual, Trans, and/or Intersex (LGBTI);
• Strengthening citizen advocacy and demand for quality health and child protection services;
• Engaging the private sector to extend the reach of SBC interventions;
• Providing technical assistance to the RGC to reform/introduce and implement laws and policies for clients and consumer rights and protection; and
• Addressing the key drivers that place children in residential care through SBC activities.

Sub-Purpose 2: Improved health financing and social health protection

USAID/Cambodia has made important contributions toward establishing social health protection (SHP) for the poor and vulnerable through the Health Equity Funds system (HEF), a major achievement for which Cambodia has received international recognition. This form of SHP is an important foundation for universal health coverage (UHC), which the RGC is committed to supporting, whereby all of the population has access to quality services without financial hardship. Improved financial protection for health is designed to support the RGC and its partners in moving toward UHC in a sustainable manner that reduces financial barriers to quality health care and catastrophic financial hardships due to medical expenses.

Illustrative Project interventions include:

●Supporting the RGC to develop and implement a robust SHP legal and governance framework, institutional arrangements, and schemes;

●Assisting the RGC to cost out and expand benefit packages of all SHP schemes (HEFs, National Society Security Fund (NSSF), and future schemes) to meet the needs of the population;

●Supporting demand-side advocacy from civil society and citizen engagement to increase public domestic resources and budget transparency for social protections; and

●Building RGC capacity to pilot innovative approaches that improve accountability, as well as allocative and technical efficiency of national and sub-national budgeting and spending, such as the use of mobile and other non-cash payments for health services.

Sub-Purpose 3: Improved quality of public and private health and social services

Improving social and healthcare service quality through a holistic and as appropriate, integrated, approach has been defined as a core principle in the strategic plans of the Ministry of Health (MoH) and the Ministry of Social Affairs, Veterans and Youth Rehabilitation (MoSVY), so as to ensure that all Cambodians are able to achieve the highest level of health and well-being.

USAID/Cambodia views quality of health care as critical for the expansion of SHP ̶ specifically, the development of a social health insurance (SHI) system in Cambodia. The Project aims to build on the success of USAID/Cambodia’s investment in health quality improvement. It will support the MoH to bring quality of health care to the next level, where health care services provided by both the public and private sectors meet a minimum acceptable standard of quality, established under the National Policy for Quality in Health. Critical elements of strengthened quality include improving health and social service delivery efficiency and effectiveness, and improving regulation and its enforcement.

Illustrative Project interventions include:

●Supporting the RGC in the development and implementation of policies and guidelines that meet global standards and improve quality and efficiency in service delivery;

●Assisting the RGC and professional councils to develop and enforce regulations, laws, and policies for licensing and accreditation of public and private health professionals and facilities, and conditioning licensure of private facilities on their employment of registered/licensed practitioners;

●Building the RGC capacity, skills, and systems for improved performance of public and private health and social service workforce;

●Enhancing health management and leadership at sub-national level;

●Strengthening and institutionalizing continuous quality improvement systems at the sub-national level for both public and private facilities;

●Supporting the RGC to implement policies and systems that help disease programs to develop, innovate, and scale up cost-effective approaches to identifying the last undiagnosed cases of HIV, finding the missing third of TB cases, and eliminating malaria infections;

●Strengthening citizen advocacy and demand for quality health and child protection services;

●Piloting a Child Protection Information Management System at the national level and in the five target provinces, and adjusted and strengthened based on experience and lessons learnt;

●Strengthening the social service workforce to improve the effectiveness of social services and support provided to children and families and to promote accessibility of family-based care options; and

●Strengthening the care system for children and families through a coordinated government response and with more educated and engaged families and communities.

The Project will implement a small percentage of activities that involve pesticides, small scale construction,and healthcare waste. The following is what the Project will be doing in these sectors:

Pesticides

Under malaria control activities in this Project, the following illustrative activities will be performed:

-Procure and supply long-lasting insecticide treated nets (LLINs) through Washington-based mechanisms;

-Support community-based organizations and groups to conduct behavior change and social mobilization activities to promote and monitor consistent LLIN use;

-Support distribution of LLINs and appropriate behavior change campaign messaging to ensure access and use of LLINs.

Malaria control activities involving the use or recommendation for use of pesticides related toinsecticide treated net (ITN) distribution and net impregnation/re-impregnation may haveminor adverse environmental impacts.

Small Scale Construction

The scope of USAID/Cambodia’s Health program is focused primarily on the provision of technical assistance, and, as such, many program activities do not have potential impacts to the environment. However, some OPHE activities may occasionally undertake minor construction, repairs and renovations to existing structures, which may include repainting walls, improving lighting and electric/network wires, improving air conditioning, etc.

The USAID/Cambodia Health Team will work with its implementing partners and collaborating agencies to ensure there is an Environmental Monitoring and Mitigation Plan in place to avoid any negative environmental impact from such activities.

Healthcare Waste

USAID/Cambodia OPHE activities will involve procurement and disposal of medical equipment andsupplies, such as condoms and hypodermic needles, which can haveminor adverse environmental impacts. Project activities that involve service delivery to clients will require disposal of medical equipment and medical waste.

Waste management will follow host country MoH guidelines by contracting local entities licensed by the MoH to handle medical waste. Clinics will collaborate with MoH referral hospitals to dispose of waste in accordance with MoH guidelines. In accordance with MoH guidelines, waste management will follow the steps below:

• Sorting: separating waste by type at the location where it is generated;
• Handling: collecting and transporting waste within the facility;
• Interim storage: storing waste within the facility until it can be disposed;
• Final disposal: eliminating or transporting solid medical waste, liquid, sharps, and hazardous chemical waste from the health facility.

Methods of medical waste treatment and disposal: methods for the treatment and disposal of medicalwastes include: incineration (burning), chemical disinfection, wet and dry thermal treatment, microwaveirradiation, land disposal, inertization and encapsulation (detailed information is described in MoHInfection Prevention and Control Guidelines for Health Care Facilities, July 26, 2010).

2.0 Country Information

1. The Ministry of Health of Cambodia, with support from the World Health Organization, has developed a National Policy on Health Care Waste Management (June 2009) and Infection Prevention and Control Guidelines for Healthcare Facilities (2010). These policies provide guidance to health care facilities in Cambodia with regards to proper measures for handling medical waste.

1. The legal requirements for Environmental Impact Assessments (EIAs) in Cambodia are set out in the Law on Environmental Protection and Natural Resource Management, 1996 (Chapter III) (EPNRM Law) and the Sub-Decree on Environmental Impact Assessment, 1999 (EIA Sub-Decree). There are also a number of Prakas (regulations promulgated by a Ministry to implement a law) on the procedures implementing the EIA Sub-Decree 1999:
   • Prakas on Guidelines for Conducting EIA Report (49 Ministry of Environment, March 2000);
   • Prakas on Determination of Service Charge for Environmental Impact Assessment Report Review and Follow-up and Monitoring of Project Implementation (No. 745, October 2000);
   • Prakas (Declaration) on General Guidelines for Conducting Initial and Full Environmental Impact Assessment Reports (No. 376 BRK.BST 2009);
   • Prakas on Registration of Consulting Firms for Studying and Preparing Environmental and Social Impact Assessment Report (No. 215 BrkMoE 2014); and
   • Prakas on Establishment of the Technical Working Group for Reviewing and Commenting on the EIA Report (No. 063 Pr.kMoE 2014).

1. There is also a Sub-Decree 146 on Economic Land Concessions (ELC), 2005, which requires environmental assessment of ELCs. Article 7, clause 5 of Sub-Decree 146 states that “if the initial environmental and social impact assessment indicates a medium or high degree of adverse impact, arrange for the conduct of a full environmental and social impact assessment.”
   
2. Cambodia is currently preparing an Environmental Code with an EIA component.Tropical forests and the conservation of biodiversity play a fundamental role in sustainable development. As such The U.S. Foreign Assistance Act (FAA) of 1961, as amended by Sections 118 and 119, requires that all USAID Missions conduct a periodic country analysis of the conservation and sustainable use of tropical forests and biological diversity. These analyses can help inform project design and implementation.

1. The USAID Cambodia Tropical Forestry and Biodiversity (118/119) Assessment can be accessed at the following website:
   

1. The Ministry of Rural Development’s Rural Water Supply, Sanitation and Hygiene Strategy 2010-2025 covers policies and procedures to ensure safe and sustained water supplies.
   

3.0 Analysis of Potential Environmental Impact

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 intended benefits. Impacts can be direct, indirect, or cumulative. They can also be beneficial or negative. The USAID Sector environmental guidelines are good resources in finding more information on potential impacts for various sectors.

The following link is to all sector guidelines:

The following are summaries of potential environmental impacts for respective sector(s) that are related to the scope of this IEE.

Pesticides

The health and environmental hazards of the pesticides proposed for use are assessed in the attached PERSUAP (Attachment1) for the Cambodia Malaria Elimination Project (CMEP). Synthetic pyrethroids used in insecticide treated nets (ITNs) pose a very low risk to humans or to the environment if used correctly. Exposure predominantly occurs as a result of improper handling of insecticides during regular re-impregnation of mosquito nets (e.g., splashing on the skin, into the eyes or through ingestion), accidents caused by insufficient awareness of pesticide risks and safe handling practices, and poorly or mislabeled containers. Minimal exposure during actual use of ITN (i.e., sleeping under the nets) can occur due to inhalation of insecticide that has volatilized from the net, dermal contact with the net and oral exposure from hand-to-mouth or direct contact. In addition, some percentage of LLINs may be re-purposed in waysthat could increase exposure to pyrethroids, such as fishing. Despite these risks, however, the beneficial impacts of bed net re-impregnation are significant, as insecticide treated bed nets are proven to be more effective in preventing mosquito bites.

To reduce the impact of pesticides used in re-treatment, CMEP will fully implement the safe use action plan of the attached PERSUAP.

Small Scale Construction
Construction projects may cause both direct and indirect potential adverse environmental impacts.

Environmental impacts of special concern include:
• Damage to sensitive or valuable ecosystems
• Compaction of the soil and grading of the site
• Sedimentation of surface waters
• Contamination of ground and water supplies
• Adverse social impacts
• Spread of Disease
• Damage to aesthetics of site/area
Construction also has potential adverse impacts on workers. Worldwide, construction is a dangerous occupation. In developing countries overall, construction is estimated to be on average 10 times more dangerous than in developed economies.
Typical health and safety risks to construction workers in developing countries include falls and falling objects, crush injuries from collapses and heavy equipment, flying debris, and exposure to toxics such as solvents, cement dust, lead and asbestos. Climates with increased temperatures may also lead to more health impacts on workers due to extreme heat stress. Occupational injuries and illnesses can permanently deprive construction workers of the ability to earn a livelihood – and are often fatal.