INITIAL ENVIRONMENTAL EXAMINATIONFACESHEET

Activity/Project Title: Improving Health and Nutritional Status in Focus Areas and Population Groups / More Effective Use of Sustainable Health Services.Program/Activity Number: 617-DCA-12-017; 617-DCA-13-019; TBDProgram/Activity Number:617-008Functional Objective: 3 Investing in PeopleProgram Area: Health

Solicitation #: [As assigned by contracting office]

Contract/Award Number (if known): Geographic Location : Uganda/East AfricaOriginating Bureau: Africa BureauSupplemental IEE: ☐ Yes ☐ NoAmendment: ☒ Yes ☐ No Programmatic IEE: ☐ Yes ☐ No

DCN and date of Original document:Uganda_DO3_Health_IEE_011516

DCN and ECD link(s) of Amendment(s): Uganda_Health_IEE Amendment #1 as revised by Mission with CRM. Approved 7/10/2017.  

http://gemini.info.usaid.gov/egat/envcomp/document.php?doc_id=5022Amendment No.: 2

Funding Amount: $50,000,000 Life of Project: 5 years Implementation Start/End: September, 2016 to September, 2023Prepared by: Health Office Team USAID/Uganda; Mission Environment Officer USAID/UgandaIEE Submitted by: Jessica Okui, Mission Environment Officer USAID/Uganda

Date Submitted: August 30, 2017

Expiration Date: September, 2023 Reporting due dates (if any): Environmental Media and/or Human Health Potentially Impacted (check all that apply):None☐ Air☒ Water☒ Land☒ Biodiversity ☒ Human Health☒ Other☐Recommended Threshold Determination(check all that apply): Negative Determination

☒ with conditions ☐ Categorical Exclusion

☐ Positive Determination☐ Deferral ☐ Exemption ☐ USG Domestic NEPA action

Additional Elements ☒ Conditions ☒ EMMP ☐ WQAP ☐Pesticides ☐ Deferred ☐Other: ESF/ERR ☒DCA

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Climate Change:☒GCC/Adaptation ☐GCC/Mitigation ☒ Climate Change Vulnerability Analysis:The climate change vulnerability analysis for the SUSTAIN Modification is LOW according to CDCS 2.0, since climate does not directly affect HIV and TB interventions. No further action is required.

Other Relevant Environmental Compliance Documentation: See DCN fields above. [cite Feb 2017 BPR] & url, or refer to Appendix B  ?

Sub Activities/Amounts:1. Loan portfolio guarantee to ECOBANK:$ 7, 000,000;2. Loan portfolio guarantee to Centenary Bank:$ 3,000,0003. Loan portfolio guarantee to DFCU:$ 5,000,0004. Loan portfolio guarantees (TBD):$ 5,000,0005. Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) Modification:

$30,000,000

SUMMARY OF FINDINGSUSAID Uganda Health sector is negotiating loan portfolio guarantee (LPG) agreements with various banks which will support Development Credit Authority (DCA) activities in USAID Uganda health sector. The purpose of this amendment #2 to the USAID/Uganda Health Initial Environmental Examination (IEE); Uganda_DO3_Health IEE_011516, is to provide the first review of the reasonably foreseeable effects on the environment, as well as recommend threshold determinations for existing and upcoming USAID /Uganda health sector DCA LPG agreements with various banks, in accordance with the requirements of Title 22 of the Code of Federal Regulations (CFR) Part 216.

This IEE consolidates threshold determinations for DCA LPG agreements managed by the Health Office implemented from September 2012 to September, 2023. Note that the earlier DCA LPG agreements were covered under an umbrella IEE but were not transitioned to the current: Uganda_DO3_Health IEE_011516.

Additionally USAID/Uganda has increased funding by $30,000,000 and the scope of the SUSTAIN activity. The purpose of this amendment #2 is to provide Reg. 216 review, and threshold determinations for this modification. Recommended Threshold Determinations:

A. Negative Determination with Conditions is recommended pursuant to 22 CFR 216.3(a)(2)(iii) for the DCA LPG agreements intended to increase the borrower’s access to loans for privately-owned and operated micro, small, and medium enterprises engaged in the Ugandan private health sector with a focus on financing equipment and clinic expansion, and loans that fall within the broad Ugandan private healthcare value-chain. This Negative Determination with Conditions is subject to conditions stipulated in Section 4 of this IEE.

B. Categorical Exclusion and Negative Determination with Conditions is recommended pursuant to 22CFR 216.2 (c)(2)(i)(ii)(iii)(v) and 22 CFR 216.3(a)(2)(iii) respectively for SUSTAIN Modification.

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This IEE Amendment #2 recommends the following environmental threshold determinations:Activities Categorical

ExclusionNegative Determination with Conditions

Positive Determination

Deferral

Loan portfolio guarantee to ECOBANK - √ -Loan portfolio guarantee to Centenary Bank

- √ - -

Loan portfolio guarantee to DFCU - √ - -Loan portfolio guarantees (TBD) - √ - -SUSTAIN Modification √ √ - -

Attachments:

Appendix A: USAID Standard Loan Provisions As Related To Environmental Compliance.

Appendix B: Recommendations of The USAID/Uganda Environmental Procedures Best Practices Review 2017 (Attachment F- Recommendations For Improvement To Health Care Waste Management)

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APPROVAL OF ENVIRONMENTAL ACTION RECOMMENDED USAID/Uganda Health Sector IEE Amendment # 2Development Credit Authority (DCAs) Loan Portfolio Guarantee Agreements and SUSTAIN Modification:

CLEARANCE:

Mission DirectorUSAID/Uganda: __________________________________ Date: ___________ Mark Meassick

CONCURRENCE:

Bureau Environmental Officer AFR/SD: ____________________________________ Date: ____9/22/2017_______

[for] Brian Hirsch

File Name: Uganda Health Sector DCA LPG & SUSTAIN Mod. IEE Amend.#2.09222017

ADDITIONAL CLEARANCES:Mission Environmental OfficerUSAID/Uganda: ________________Cleared _______ Date: 09/06/2017

Jessica Okui

Ag. Health Office DirectorUSAID/Uganda: ___________________________________ Date: ___________

Michelle Lang-Alli

Mission Climate Change Integration LeadUSAID/Uganda: ________ Cleared_______________________ Date: 09/06/2017

Shawna Hirsch

Ag. Deputy Mission DirectorUSAID/Uganda: __________________________________ Date: ____________

Laura Ganzalez

Regional Environmental AdvisorUSAID/East Africa: ___________Cleared _____________ Date: 09/06/2017 David Kinyua

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INITIAL ENVIRONMENTAL EXAMINATIONUSAID/Uganda Health IEE Amendment #2

PROGRAM/ACTIVITY DATA Country/Region: Uganda/East AfricaProgram/Activity Title: USAID/Uganda Health Sector DCA LPG Agreements Program /Activity Title: Improving Health and Nutrition Status in Focus Areas and PopulationsProgram/Activity Number: 617-DCA-12-017; 617-DCA-13-019; TBDProgram/Activity Number: 617-008

1.0 BACKGROUND AND ACTIVITY/PROGRAM DESCRIPTION

1.1 Purpose and scope of the IEEUSAID Uganda Health sector is negotiating loan portfolio guarantee (LPG) agreements with various banks which will support DCAs LPG agreements in USAID Uganda health sector. The purpose of this amendment #2 to the USAID/Uganda Health Initial Environmental Examination (IEE); Uganda_DO3_Health_IEE_011516 , is to provide the first review of the reasonably foreseeable effects on the environment, as well as recommend threshold determinations for existing and upcoming USAID /Uganda health sector DCA LPG agreements with various banks, in accordance with the requirements of Title 22 of the Code of Federal Regulations (CFR) Part 216.

This IEE consolidates threshold determinations for DCA LPG agreements managed by the Health Office implemented from September 2012 to September, 2023. Note that the earlier DCA LPG agreements were covered under an umbrella IEE but were note transitioned to the current: Uganda_DO3_Health_IEE_011516 .

Additionally, USAID/Uganda has increased funding by $30,000,000 and the scope of the SUSTAIN activity. The purpose of this amendment #2 is to provide Reg. 216 review, and threshold determination for this modification.

In the event that any new proposed DCA LPG agreement, and SUSAIN modification differs substantially from the type or nature described here or requires different or additional mitigation measures beyond these described, this IEE amendment #2 shall further be amended.

1.2 BackgroundAll details in this section remain as described in the original IEE, (File name: Uganda_DO3_Health_IEE_011516), and is cross referenced in this amendment.

1.3 Description of Activities:

Loan Portfolio Guarantees: The Private Health Support Project (PHSP) provides technical assistance to lenders with the loan portfolio guarantees. PHSP assists with management of the loans and attends to quality assurance considerations. PHSP currently provides DCA TA to Centenary Bank and is working with DFCU to finalize this new DCA in health.

a. Loan Portfolio Guarantee to ECOBANK. This Guarantee is intended to strengthen the Guaranteed Party's ability to finance loans to borrowers in Uganda who are engaged in the Ugandan private health sector, with a focus on

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financing equipment and clinic expansion. Qualifying projects are loans that fall within the Ugandan private healthcare value-chain (including privately owned hospitals and clinics; retail d ispensaries; service delivery franchisers; health insurance providers; personal loans for housing and education for health care workers; and medical equipment and transportation inves tments by and for use of healthcare providers as a business investment).

b. Loan Portfolio Guarantee to Centenary Bank:Qualifying borrowers are Ugandan privately-owned and operated micro, small, and medium enterprises in the health value chain; and Ugandan healthcare workers (including, retail dispensaries, service delivery franchisers, community health insurance providers, personal loans for housing and education for health care workers, and transportation investments by and for the use of healthcare providers as a business investment).

c. Loan Portfolio Guarantee to Development Finance Company of Uganda (DFCU) Bank:The proposed 5 year tenor guarantee with DFCU is intended for health lending, with a special focus on leasing of medical equipment. DFCU is well positioned to take advantage of this opportunity, being the market leader in asset financing and leasing. Medical equipment financing would be a perfect product/market fit for its credit growth strategy. Under the proposed DCA, USAID/Private Health Support Program will be the technical assistance (TA) provider to the bank to implement a health lending strategy to maximize the utilization of this DCA. This includes assistance in better understanding the market, loan officer training, strategy development, and pipeline development support. These skills will assist banks to better understand the risks associated with lending to the health sector, such as low turnover and possible delinquency. Developing loan products more tailored for the health sector will also require an improved understanding by the banking industry of the healthcare market.

d. TBD Loan Portfolio Guarantees, within the Health Sector:Future DCA LPG agreement in the Health sector. The loans must not be used to finance any of the following without the prior written approval of USAID (activities likely to have significant effect on the environment. (Refer to Appendix A: USAID standard loan provisions as related to environmental compliance) 

SUSTAIN Modification Interventions: Through this modification, SUSTAIN will continue to focus on delivery of high quality HIV prevention, care and treatment as well as advanced TB diagnosis and management services. Based on lessons learned from other partners and preliminary data from the Uganda Population HIV Impact Assessment (UPHIA), SUSTAIN will specifically focus on:

a. Scaling up high impact HIV prevention services through: Increasing access to HIV counseling and testing services (HTS) for men and other priority

populations, and increasing “yield” across all supported testing sites; Improving referrals and linkages so that all HIV-positive clients identified are immediately

enrolled in care and treatment; Building capacity of health providers in the new HTS strategy as well as disseminating new

national HTS policy and guidelines; Supporting the elimination of mother-to-child transmission (eMTCT) services among HIV-

exposed children to less than 3 percent in all targeted facilities. The overarching goal is to provide HTS to more than 95 percent of all pregnant women; strengthen counseling services; facilitate mother-baby-care points and family support groups in all eMTCT sites;

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Ensuring that birth cohort monitoring and maternal retention are implemented across all supported PMTCT facilities with the goal of achieving greater than 95 percent retention of mother-baby pairs enrolled in the eMTCT program; and

Prioritizing family planning/HIV integration and increasing access to early infant diagnosis (EID) services for more than 95 percent of HIV-exposed infants.

b. Further expanding access to Antiretroviral Therapy (ART) through: Rolling out the new Consolidated Guidelines for Prevention and Treatment of HIV in

Uganda. This will entail fast tracking the training of clinical staff and adoption of test and treat in all supported health facilities;

Implementing differentiated service delivery models for HIV/AIDS care and treatment for effective use of resources;

Strengthening linkages across the HIV continuum of care and other health programs to maximize identification and prompt enrollment of HIV-positive individuals in care;

Strengthening access to HIV/AIDS disease monitoring and improve coverage of viral load testing and CD4, where appropriate, through the ‘hub and spoke’ model and effective sample transportation networks;

Building capacity for efficient maintenance of key HIV/AIDS and other essential health care equipment to minimize down time; and

Scaling up the implementation of high-impact TB/HIV interventions, including MDR-TB interventions to increase treatment success and case detection rates.

c. Ensuring quality of HIV/AIDS/TB services:SUSTAIN will build the capacity of health workers to provide quality TB/HIV/AIDS services through technical training based on MoH curricula and national scale-up plans, guidelines and revised policies. SUSTAIN will use national trainers seconded by Ministry of Health to train trainers at the regional level, who will in turn train the lower health facilities. These trainings will be followed with mentoring and coaching to ensure that the skills obtained are applied by the health workers. SUSTAIN will further support health facilities to submit timely and adequate orders of essential health commodities to NMS and JMS.

d. Building partnerships:SUSTAIN will strengthen partnerships with districts and communities through joint district supportive supervision of sites, shoring up the role of health management committees in supervising HIV/AIDS/TB services at sub-county and community level as well as sharing data and findings from SIMS and other supervision visits with sites and districts.

The description of the existing activities, which have not been modified, are described in the original IEE, (Uganda_DO3_Health_IEE_011516), as cross-referenced in this amendment.

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2.0 COUNTRY AND ENVIRONMENTAL INFORMATION (BASELINE INFORMATION):

2.1 Locations Affected:All details in this section remain as described in the original IEE, (Uganda_DO3_Health_IEE_011516), as cross-referenced in this amendment.

Additionally SUSTAIN will support HIV/TB prevention, care and treatment services in two Regional Referral Hospitals of Gulu and Lira as well as 137 lower level health facilities currently supported by ASSIST. SUSTAIN will further take on eight faith-based sites formerly supported by CDC through TASO, Uganda Catholic Medical Bureau and the Uganda Protestant Medical Bureau. These sites include: Lacor, St Joseph Kitgum, Kalongo, Pope John’s Hospital Aber, Amai, Pentecostal Assemblies of God (PAG) Lira hospitals as well as TASO Gulu and New Life Clinics.

2.2 Environmental Baseline:USAID/Uganda’s Environmental Threats and Opportunities Analysis (ETOA), completed in 2015, summarizes key features of the natural environment as: Uganda is a landlocked country on the equator, covering 241,551 sq. km. Approximately 20% of the surface area of Uganda is covered by aquatic systems comprising of five major lakes; (Victoria, Kyoga, Albert, George and Lake Edward) the Kazinga Chanel, about 160 minor lakes and an extensive river system, dams and ponds. The aquatic systems are usually fringed with extensive wetlands. Uganda is among the richest countries with respect to its natural environment. The country has a wide variety of physical environmental features, ranging from tropical forests to grasslands, extensive surface drainage pattern (e.g. lakes, rivers, streams, etc.), and arid and semi-arid areas to snow-capped Rwenzori Mountains range. The country has seven of Africa's 18 bio-diversity geographic regions, which is the highest concentration on the continent, and some 90 different vegetation communities.

Given Uganda’s location in a zone between the ecological communities that are characteristic of the drier East African savannas and the moist West African rain forests, combined with high altitude ranges, the country has a high level of biological diversity. Uganda ranks among the top ten most bio-diverse countries globally. Most of Uganda’s biodiversity is found in the natural forests, but a considerable numbers is also found in other natural ecosystems such as mountains, savannahs, wetlands, lakes, and rivers. Uganda's is an exceptionally important area for bio-diversity conservation. The natural resource base, especially its wide diversity of wildlife, is the country's greatest biological and economic asset for sustainable tourism industry development. More than 18,783 species of fauna and flora are recorded: Approximately 5,000 species of higher plants; lower plants- algae (115 species), pteridophtes/ferns (386 species), bryophytes/mosses (500 species), liverworts (250 species); mountain gorillas 53.9% (400 individuals); World’s recorded bird species 11% (1,063 species)- representing 50% of Africa’s bird species; Uganda is second in Africa in number of mammal species (345 species), 15 mammal species and sub-species are endemic to Uganda, nine species of primates are known, including the mountain gorilla, the red Columbus monkey and the chimpanzee. Over half (53.9%) (400 individuals) of the world's remaining population of mountain gorillas are found in Uganda ; butterflies (1,249 species); fish ( 600 species); amphibians (98 species); reptiles (150 species); insects (8,999 species). The cichlid family consisting of 324 species of which 292 are endemic to Lake Victoria (NEMA 2012) dominates the fish diversity in Uganda. Lakes Victoria, Kyoga, and George are of international importance in the conservation of endemic wetland species.

Conservation of key bio-diversity resource areas is a well-demonstrated priority of the Uganda Government. About 13percent of the country's land area is protected under a comprehensive system of national Parks, Wildlife Reserves and Forest Reserves. The Uganda wildlife Authority and the Forest Department manage these areas.

Uganda’s biodiversity faces a wide range of threats, and is at significant risk. The USAID/Uganda Environmental Threats and Opportunities Analysis (ETOA) completed in 2015 identified the following threats to biodiversity

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and forest in order of importance: Agricultural expansion into natural ecosystems: Agriculture potentially threatens the vitality and

health of wetlands through draining of water and clearing wetland vegetation, especially seasonal woodlands, bush, and thickets, negatively affecting their capability to provide ecosystem services (Turyahabwe et al., 2013). Furthermore, the promotion of commercial crops reduces available arable land for the rural poor, which may force them to encroach on forests and other natural ecosystems;

Charcoal/firewood collection: Biomass is the dominant energy resource for household as well as for small and medium scale industries.92% of Uganda’s energy needs are met from woody biomass (NEMA, 2014a). Fuel wood currently contributes more than 96% of energy for cooking in Uganda (NEMA 2014b). Charcoal production increased from 7,975,000tons in 2009 to 10,449,000tons in 2013; during the same period, fuel wood for household use increased from 21,905,000 to 25,196,000 (UBOS 2014);

Infrastructure development: Urban expansion, energy development, mining. Urbanization and industrialization have exerted pressures mainly on peri-urban forest reserves and wetlands for expansion of urban and industrial centers. 30%of Uganda’s wetland ecosystem or 4.7% of Uganda land area has been lost just in 15 years (NEMA 2014a);

Illegal activities: Poaching (wildlife, fisheries, timber) and wildlife trafficking. Illegal activities affecting biodiversity inside and outside protected areas, and in wetlands, and water bodies include hunting for subsistence, commercial trading of wildlife and wildlife products (meat, skins, and other trophies) pit sawing and fishing. Animals most affected are elephants for ivory, hippos mainly for meat, sitatunga and other antelopes for subsistence consumption, and pangolins for their scales;

Human-Wildlife conflict: These conflicts occur as a result of movement of wildlife form inside to outside protected areas. These are occurring as a result of increased interference between people and wildlife; destruction of crops by elephants, chimpanzees etc.;

Pollution: This results from agricultural, industrial, and municipal waste discharge and dumping. This poses a potential threat to biodiversity through habitat modification or loss (NEMA 2014);

Climate change: An over view of Climate Change and Biodiversity (USAID 2014) states “Biodiversity and ecosystem-specific goods and services in Uganda are likely to be adversely affected by climate change in the future. According to projections, Uganda will continue to experience rising temperatures, which will increase by more than 2 °C by 2030 (Tetra Tech ARD, 2013). Additionally, the growing variability of inter-annual rainfall is projected to continue, including increased rainfall during the dry season. These new climate scenarios are expected to increase the frequency of floods, droughts, and fires. This overview1 provides an assessment of how biodiversity and ecosystem services are likely to be affected by climate change in the geographical regions of the Albertine Rift and Karamoja, as well as potential adaptation strategies for addressing these impacts” ;

Zoonotic diseases: Zoonotic disease and vector-borne diseases form more than 70% of the global emerging and reemerging disease burden. Zoonotic diseases are known to be very aggressive and contagious. Passed from animals to humans and vice versa. Uganda has experienced eight such out breaks in the past years (Nabukenya et al., 2014);

Invasive species: This is priority concern for protected area management. Invasives are affecting nearly half of all the National Parks; Queen Elizabeth Conservation Area, Lake Mburo National Park, Kidepo Valley Conservation Ares, Murchison Falls Conservation area etc.;

Over –exploitation of natural ecosystems; especially forests, wetlands, rangelands, and fisheries; Transboundary threats; and Human-induced wildfires.

Consequently, the following are the underlying causes of biodiversity threats described above: Population growth; Weak Governance, including weak implementation, conflicting, and overlapping mandates; Limited opportunities for off-farm employment;

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Poverty; Insecurity of land tenure; an Government policies that fail to promote conservation; and Climate change.

Three regions of Uganda have particularly important biodiversity. These are: Western Uganda forms part of the Albertine Rift Region, which is one of Africa’s most important

regions for biodiversity. About half of the entire population of the mountain gorilla (Gorilla gorilla berengei) lives in the extreme southwestern part of this region; Lakes George and Edward have 79 species of fish. Three of these species are endemic to Uganda (Varicorhinus ruwenzori, Microcteriopoma damasi and Hypsopanchax modestus) (NEMA, 2009). An endemic species of papyrus (Chloropeta gracilirrostris) grows in the shallower parts of Lakes Edward, George, and Bunyonyi;

In the Southern Central Region, Lake Victoria, the lakes of the Kyoga basin and Sango Bay originally had more than 600 endemic haplochromine cichlids; they also have important biodiversity that, due to the island nature, is extremely fragile. This gives the southern portion of Central Uganda its particular importance for biodiversity (NEMA, 2009); and

Northeastern Uganda is important for biodiversity because a number of species are endemic to this area and areas of Kenya and Southern Sudan. The species include 30 species of birds, among which are the Karamoja Apalis (Apalis karamojae), a threatened species, and several species of butterflies, including Papilio nobilis and Charaxes smaragdilis elgonae, the cheetah (Acinonyx jubatus), lesser kudu (Tragalaphus imberbis), greater kudu (Tragalaphus strapsiceros), roan antelope (Hippotragus equines), Secretary bird (Sagittarius serppentaris) and ostrich (Struthio camelus).

Climate: Uganda has a tropical climate, with temperatures ranging from 21-25°C, apart from in the mountainous areas, which are much cooler; the top of Mount Rwenzori is often covered with snow. The hottest months are July to September and December to February. Evenings can feel chilly after the heat of the day with temperatures around 12- 16ºC. Most regions of Uganda, apart from the dry area in the north, have an annual rainfall of between 1,000mm and 2,000mm. There is heavy rain between March and May and between October and November (NEMA 2014).

In 2012, USAID/Uganda commissioned a climate change vulnerability assessment. Results of the assessment indicate that temperatures have and will continue to increase in Uganda and, although average total precipitation is projected to stay the same, the country may experience an increase in rainfall during the dry season and an increase in extreme events such as droughts and floods. The assessment’s livelihood analysis indicates that 73% of households surveyed are highly vulnerable to climate change impacts because of their reliance on sensitive crops and their lack of assets, financial capital, and non-agricultural sources of income that can be used at times of stress. Additionally as a result of global climate change, Uganda is experiencing melting glaciers in the Rwenzori Mountains, and increasing intensity and frequency of dry spells and floods. This has led to increasing prevalence of agricultural pests and human diseases (e.g. malaria). Furthermore, Biodiversity and ecosystem-specific goods and services in Uganda are likely to be adversely affected by climate change.

Topography: Uganda is divided into four relief regions: Above 2,000m – 2% of the land area; 1,500–2,000m – 5% of the land area; 900–1,500m – 84% per cent of the land area; and Below 900m – 9% of the land area.

A large part of Uganda forms part of the interior plateau of the African continent. The Rwenzori Mountains and the Mufumbira volcanoes in the West; and Mt. Elgon, Mt. Moroto, Mt. Morungole, Mt. Timu and Mt. Kadam in the East (NEMA 2002) represent the plateau in the eastern and western parts of the country.

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Soils: The most dominant soil type is ferralitic soil which accounts for about 2/3 of the soils found in the country. According to Parsons (1970), the soils of Uganda have been classified as:

Soils of high productivity constituting 8% of the land area; Soils of medium productivity covering 14% of the land area; Soils of fair productivity constituting 43 % of the land area; Soils of low productivity constituting 30% of the land area; and Soils of negligible productivity constituting 5 % of the land area (FAO 2006).

Water resources: Uganda is endowed with significant surface and ground water resources which consist of open water bodies (lakes and rivers), wetlands, groundwater, and rain water. Of the 241,500 km2 total area of the country, fresh water lakes occupy 36,280 km2 (15%).

Wetlands: Uganda presently has 12 sites designated as Wetlands of International Importance, with a surface area of 454,303 hectares. Wetlands occupy an estimated 13 % of Uganda’s national territory and serve a number of functions. They serve as storehouses for fresh water and nurseries for fish; they sustain high levels of biodiversity and represent important bird areas; some act as basins for tertiary treatment of urban wastewater; and many people depend for their livelihoods on wetland resources. However, the wide distribution of wetlands and the lack of protective mechanisms mean that a large proportion of the population has access to wetlands, which is resulting in extensive degradation and biodiversity loss. According to a 2012 NEMA report, wetlands in 2008 covered approximately 10.9 % of the land surface area, down from 15.6 percent in 1994 (MWE, 2012). The ongoing, overall decline in wetlands, particularly in the Lake Victoria and Lake Kyoga drainage basins, is largely attributed to encroachment for expansion of urban centers, housing settlements and industrial developments, and extension of agricultural land driven by declining soil productivity on the uplands, pushing people to farm in lowlands, exacerbated by complex land ownership issues.

Forest resources: Forests and woodlands cover approximately 4.9 million hectares in Uganda, about 24 % of the total land area in 2012 (UIA, 2012). The vast majority of this is woodland (19%), while the rest is tropical moist forest (5 %) and forest plantations (0.2%). According to the National State of Environment Report (NEMA 2012) Uganda’s forests and woodland resources contribute 2% of the national GDP, however the deforestation rate is estimated at 1.8 % per year. Between 1995 and 2005 Uganda’s forest area decline from 24 % to 18 % of the land area at a deforestation rate of 18%. Uganda has lost more than 3 million hectares of forest cover since 1990 (NFA, 2015). This is almost 30 % of the 1990 forest coverage acreage. The main factors at play are the rapid expansion of farmlands, rapidly growing human population, and increased urbanization (NEMA, 2012). In the recent past, the tendency for people to migrate out of the increasingly crowded city into the suburbs of Kampala has seen the forest coverage in the districts of Wakiso, Mukono and Mpigi reduce to 22 percent of what they were during 1990 (NFA, 2011).

Population: Population is an important factor that affects environmental management in Uganda. It affects the availability and renewability of natural resources. The use of natural resources is directly proportionate to population increase. A vast majority of Uganda’s population is very dependent on natural resources. For example the decline in forest cover at 1.8 percent per annum is attributed to the increasing demand of land for agriculture and fuel wood by the rapidly increasing population growth.

Uganda’s population is about 34.9 million people from 8 million people at the time of independence in 1962. The 2014 census revealed an increase of 10.7million, from 24.2 million given by the 2002 census. This gives an annual growth rate of 3.03%, giving an estimated population of 42.4 million people by 2020. The average household size is 4.7 persons, with a sex ratio of 94.5 males per 100 females. An estimated 72% of the population lives in rural area as compared to 28% in the urban centers. 49% of

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Uganda’s population is under the age of 15 and with 18.9% of the total population being under- five.

Population Number %Total 34.9 million 100%Children aged 0-59months (under five years) 6.6 million 18.9%Women of reproductive age (15-49 years) 7.3 million 20.9%Population that is 15 years of age 17.0 million 48.7% Population of adolescents (10-19 years of age) 8.6 million 24.5%

Source: National Population and Housing Census 2014

Despite Uganda’s success in reducing poverty, more than 7.5 million Ugandans still live in poverty, surviving on income below the minimum that is required to meet their basic needs partly due to high population (MFPED 2012). The incidence of poverty remains higher in rural areas than in urban areas. The rural areas with 85% of the population constitute 94.4% of national poverty. These results suggest that the majority of the poor are in rural areas. The incidence of poverty remains highest in the Northern region and least in the Central region. On average, poverty incidence in Northern region (46.2%) remains higher than the national average (24.5%) (UBOS 2010).

Health Sector: The Health sector aims at achieving Uganda’s vision 2040 of a healthy and productive population that contributes to socio economic growth and national development the goal of the health sector plan is to accelerate movement towards Universal Health Coverage with essential health and related services needed for promotion of a healthy and productive life.The achievement realized under the Health Sector Strategic and investment Plan 2010/11 -2014/15 include among others;

Reduction of maternal mortality ratio from 438/100,000 (UDHS) live births in 2011, to 360/100,000 (World Health Series (WHS) estimates) live births in 2014;

Reduction in under five mortality from 128/100 live births in 2006, to 90/1000 in 2011, to 69/1000(WHS estimates) in 2014; and

Reduction in infant mortality rate from 71/1000 live births in 2006, to 54/1000 in 2011 and 45/1000 (WHS estimates) in 2014.

Source: Health Sector Development Plan 2015/16-2010/20.

According to PRB (2012), Uganda’s life expectancy is estimated to be 54 years on the average. Uganda has gained in life expectancy from 45 years in 2003 to 54 years in 2012. Although there is a gain in life expectancy, it is still very low compare to developed countries which have life expectancy of 70 years and above.

HIV/AIDS: Uganda is still classified as a high burden country with high number of persons living with HIV which has continued to increase. This is a result of continuing spread of HIV, and increased longevity among persons living with HIV. The national projections based on spectrum estimates indicate an increasing number of people living with HIV; 1.4million in 2011 to 1.6M in 2013, and to 1,500,000 in 2014 and high number of orphans due to AIDS of about one million.; However, there is a window of hope as evidenced by reduction in number of new infections among the adults over the last five years from 160,000 in 2010 to 140,000 in 2013 and to 95,000 in 2014. Similarly the new infections among the children reduced from 31,000 in 2010 to 15,000 in 2013 and to 5200in 2014. Other remarkable improvements have been witnessed in the reduction of annual AIDS related deaths from 67,000 to 63,000 in 2010 to 2013 respectively and to 31,000 in 2014. (Source: The HIV AIDS Uganda County Progress Report 2014)

Malaria: Malaria is highly endemic in most of the country, and Uganda has some of the highest transmission

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rates in the world. Accounting for 34 % of outpatient visits and 28% of hospital admissions, malaria places a heavy burden on the Ugandan health system. Plasmodium falciparum is the major source of infection.

2.3 National Environmental Policies and Procedures:All details in this section remain as described in the original IEE, (Uganda_DO3_Health_IEE_011516), and is cross-referenced in this amendment.

3.0 EVALUATION OF ACTIVITIES WITH RESPECT TO ENVIRONMENTAL IMPACT POTENTIAL:

22CFR 216.2 (c)(x) Support for intermediate credit institutions when the objective is to assist in the capitalization of the institution or part thereof and when such support does not involve reservation of the right to review and approve individual loans made by the institution. However, there are concerns that some of the activities funded under DCAs may adversely affect the environment. USAID requires that the guaranteed party has in place environmental review procedures that identify those activities and ensures that appropriate mitigation measures are put in place.

The DCAs LPG agreements to be issued will only cover investment in Health sector interventions as described in section 1.3 above. The DCAs LPG agreements shall provide credit guarantee to the various banks (guaranteed party) , therefore there are no direct environmental impacts. However, downstream from USAID’s involvement, certain projects could result in a wide range of environmental and social impacts.

Some of the SUSTAIN Modification interventions may not have direct adverse environmental impacts, as they will entail improving services delivery, building capacity strengthening linkages etc. However other interventions involving generation, storage and disposal of health care waste; procurement storage, management and/or disposal of public health commodities including pharmaceuticals drugs, medical kits, supplies and/or chemical reagents, may have adverse impacts on the environment. Details in this section remain as described in the original IEE, (Uganda_DO3_Health_IEE_011516 ) , and are cross-referenced in this amendment.

4.0 RECOMMENDED THRESHOLD DETERMINATIONS AND CONDITIONS (INCLUDINGMONITORING REQUIREMENTS)/ MITIGATION MEASURES:

A Negative Determination with Conditions is recommended pursuant to 22 CFR 216.3 (a)(2)(iii) for the DCAs LPG agreements intended to increase the Borrower’s access to loans for interventions in USAID/Uganda Health sector, subject to the following conditions:

i. The loans must adhere to USAID Standard Provisions in Appendix A.ii. The Guaranteed Party shall for review by the USAID Mission Environmental Officer (MEO) and

the Regional Environmental Advisor (REA) a copy of its environmental policies and procedures as a condition precedent to the Guarantee Agreement.

iii. USAID, including the MEO and REA, will evaluate the lender’s environmental policies for sufficiency to ensure compliance with the environmental provisions of the standard language in the Guarantee Agreement.

iv. If the lender’s capacity is judged, in this evaluation, to be insufficient, USAID/Uganda will provide for appropriate lender capacity building. This capacity building activity will be designed in coordination with the MEO and REA.

v. USAID/Uganda Health Office will periodically review the Guaranteed Party’s and Borrowers

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implementation of the above, including during project monitoring visits.vi. Environmental compliance will comprise one of the performance measures of the activities’ mid

and /or end term technical evaluation to be carried out by USAID/Uganda Health Team.vii. Mandatory reference: The USAID Sector Environmental Guidelines

(http://www.usaidgems.org/sectorGuidelines.htm) must inform compliance with these conditions

General Implementation and Monitoring Requirements: - When implementing partners (IPs) are identified, the A/COR will brief them on environmental

compliance responsibilities, IEE conditions, reporting requirements, integration of environmental compliance requirements in activity budgets, and documentation coverage;

- The A/COR shall ensure that any future contracts or agreements for implementation of activities and/or significant modification to current contracts or agreements shall reference and require compliance with the conditions set out in this IEE, as required by ADS 204.3.4.a.6 and ADS 303.3.6.3.e;

- IPs shall ensure that sub-grantees and subcontractors have the capability to implement the relevant requirements of this IEE. The IP shall, if and as appropriate, provide training to sub-grantees and subcontractors in their environmental compliance responsibilities and in environmentally sound design and management (ESDM) of their activities;

- As part of IPs’ Annual Work/Implementation Plans, IPs, in collaboration with their A/COR, shall review all ongoing and planned activities to determine if they are within the scope of this IEE;

- If activities are outside the scope of this IEE, an IEE amendment shall be prepared and approved prior to implementation of any such activities; and

- As required by ADS 204.5.4, designated personnel will actively monitor and evaluate whether the program and its activities remain consistent with the approved environmental compliance requirements. If new or unforeseen consequences arise during implementation, an IEE amendment will be developed.

A Negative Determination with Conditions is recommended pursuant to 22 CFR 216.3 (a)(2)(iii) for SUSTAIN Modification interventions involving generation, storage and disposal of health care waste; procurement storage, management and/or disposal of public health commodities including pharmaceuticals drugs, medical kits, supplies and/or chemical reagents.

Table1: Recommended threshold determination and conditions for each activity group:

Activities Recommended Threshold Determinations and Conditions

4.1 Categorical Exclusion Categorical Exclusion, per 22 CFR 216.2(c)(2):(i) Education, technical assistance or training(iii) Analyses, studies, academic or research workshops and meetings;(v) document and information transfer(viii) 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, etc.)

No further environmental review required.

Activities will have no adverse impacts on the environment:

SUSTAIN Modification interventions involving: Capacity building; providing technical assistance; strengthening linkages; building partnerships; information transfers ; trainings etc.

4.2 Negative Determination with A Negative Determination with Conditions recommended pursuant to 22 CFR 216.3(a)(2)(iii) for these activities:

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Conditions

4.2.1 Activity Group 1: A Negative Determination with Conditions is recommended for SUSTAIN Modification for

(i) SUSTAIN Modification: Generation, storage and disposal of Special Medical Wastes, e.g. HIV testing, TB testing and laboratory-related activities.

(ii) SUSTAIN Modification:Procurement storage, management, and/or disposal of public health commodities including pharmaceuticals drugs, medical kits, supplies, and/or chemical reagents.

Activity Group 1 Conditions:Conditions for (i): Generation, storage and disposal of Special Medical Wastes, e.g. HIV testing, TB testing and laboratory-related activities. All details in this section remain as described in the original IEE, (File name: Uganda_DO3_Health_IEE_011516), and is cross-referenced in this amendment.

Recommendations of the USAID/Uganda Environmental Procedures Best Practices Review 2017 (Attachment F- Recommendations for improvement to health care waste management), shall be adhered to.

Conditions for (ii): Procurement storage, management, and/or disposal of public health commodities including pharmaceuticals drugs, medical kits, supplies and/or chemical reagents.All details in this section remain as described in the original IEE, (File name: Uganda_DO3_Health_IEE_011516), and is cross-referenced in this amendment.

Recommendations of the USAID/Uganda Environmental Procedures Best Practices Review 2017 (Attachment F- Recommendations for improvement to health care waste management),shall be adhered to.

4.2.2 Activity Group 2DCA LPG Agreements.

Conditions:(i) Refer to Appendix A: USAID standard loan provisions as related to environmental compliance; and(ii) General Implementation and Monitoring Requirements (refer to page 13 above).

Monitoring and Compliance Assurance:All details in this section remain as described in the original IEE, (File name: Uganda_DO3_Health_IEE_011516), as cross-referenced in this amendment.

General project implementation and monitoring requirement:All details in this section remain as described in the original IEE, (File name: Uganda_DO3_Health_IEE_011516), as cross-referenced in this amendment.

Appendix 1 of USAID Uganda Health Activity Environmental Mitigation and Monitoring Plan: All details in this section remain as described in the original IEE, (File name: Uganda_DO3_Health_IEE_011516), as cross-referenced in this amendment.

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APPENDIX A: USAID STANDARD LOAN PROVISIONS AS RELATED TO ENVIRONMENTAL COMPLIANCEUSAID Standard DCA Loan Provisions include the proviso that approval of loans will be contingent upon the submission by the Guaranteed Party of evidence sufficient to demonstrate compliance with local environmental laws and to enable USAID to make an assessment of the environmental impact of such activities.(a) The Loan must not be used to finance any of the following:

(i) Goods or services which are to be used primarily to meet military requirements or to support police or other law enforcement activities;(ii) Surveillance equipment;(iii) Equipment, research and/or services related to involuntary sterilization or the performance of

abortion as a method of family planning; or(iv) Activities which significantly degrade national parks or similar protected areas or introduce

exotic plants or animals into such areas, (b) The Loan must not be used to finance any of the following without the prior written approval of USAID:

(i) Pharmaceuticals;(ii) Pesticides;(iii) Logging equipment;(iv) Luxury goods (including alcoholic beverages and jewelry);(v) Establishing or expanding any enterprise that will export raw materials that are likely to be in

surplus in world markets at the time such production becomes effective and that are likely to cause substantial injury to U.S. producers;

(vi) Activities which would result in the loss of forest lands due to livestock rearing, road construction or maintenance, colonization of forest lands or construction of dams or other water control structures;

(vii) Activities which are likely to have a significant adverse effect on the environment, including any of the following (to the extent, such activities are likely to have a significant adverse impact on the environment):

Programs of river basin development; Significant irrigation or water management projects (including dams and impoundments); Agricultural land leveling; Major drainage projects; Large scale agricultural mechanization; New lands development; Resettlement projects; Penetration road building or road improvement projects; Construction of power plants or industrial plants; or Large scale potable water and sewerage projects

(viii) Activities which are likely to involve the loss of jobs in the United States due to the relocation or expansion outside of the United States of an enterprise located in the United States, or

(ix) Activities which the Guaranteed Party is aware are reasonably likely to contribute to the violation of internationally recognized rights of workers.

Approval of loans to finance activities described in subsections (ii), (iii), (vi) or (vii) above will be contingent upon the submission by the Guaranteed Party of evidence sufficient to demonstrate compliance with local environmental laws and to enable USAID to make an assessment of the environmental impact of such activities.

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APPENDIX B: RECOMMENDATIONS OF THE USAID/UGANDA ENVIRONMENTAL PROCEDURES BEST PRACTICES REVIEW 2017 (Excerpts from Attachment F: Observations on Health Care Waste Management from Field Visits and Potential Improvements to Health Care Waste Management at Clinics)

Potential Improvements to Health Care Waste Management at Clinics to be considered by USAID technical staff.

These options were included for discussion by the competent USAID/Kampala technical staff and can be combined and modified according to staff decisions.

1) Option One: Health clinics take on responsibility for all HCW (except highly infectious).  PPPs collect and dispose of highly infectious wastes.

a. Regional high temperature incinerators built/operated by public-private partnerships (PPPs). Regional incinerators will handle only highly infectious wastes (red) and will be for profit operations.

b. Health clinics (HCs) will build/operate/maintain furnaces/incinerators on HC grounds for infectious waste (yellow)

c. HCs will segregate, collect and dispose of wastes by three waste streams.

2) Option Two: Health clinics take on complete responsibility for HCW generateda. HCs build/operate/maintain small scale furnaces/incinerators for infectious waste (yellow)b. Ash pits will be used to isolate ashc. Sharps will be stabilized by cementing boxes (or using other materials recommended by WHO

3) For all options: Overall Management and Accountability.a. Assign HCW Manager with responsibility for all HCW generated at each HCb. Hold highest level of management at each HC accountable for HCW management at his/her

facility.c. Develop/implement/update HCW management plan per WHO recommendations.

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