Attachment_J.1_HSS_SOO_for_Amendment_1.pdf

Attachment J-1 Statement of Objectives

1. ACTIVITY TITLE

The activity title is Strategic Technical Assistance for Improved Health System Performance and Health Outcomes (STAIP).

2. INTRODUCTION

This Statement of Objectives (SOO) describes the intended results of the STAIP activity that will improve health system performance and strengthen delivery of primary maternal and child health, family planning and malaria services in public health facilities operating under the Ministry of Health for improved health outcomes. This SOO is provided in lieu of a U.S.

Government (USG) written statement of work (SOW) in that it does not state how the work is to be accomplished, but provides potential offerors with the flexibility to develop cost-effective solutions and the opportunity to propose innovative approaches to meet the stated objectives.

This activity emphasizes achievement of measurable, high-quality and cost-effective results to support the Government of Liberia (GOL) to plan, finance and implement solutions to its own development priorities. Additionally, this activity places a premium on strong financial management, evidence-based learning and adaptation fueled by innovation, technology and partnerships. Training should be a limited solution to address results proposed in this SOO as training, while important, is not necessarily a means to sustainable health systems strengthening.

Based on this SOO, a Performance Work Statement (PWS) must be submitted that describes the approach to achieve the objectives of the activity. The PWS must enable USAID to assess the performance of the work against specific, clear, and measurable performance standards (i.e., in terms of quality, quantity, timeliness, etc.) and show the method of assessing contractor performance against the performance standards. This award is approximately a $17-20 million, four year award, subject to the availability of funds.

3. OVERVIEW

USAID intends to support the strengthening of the Ministry of Health’s (MOH) systems in order to improve patient outcomes at primary health care facilities by providing sustainable capacity building and incentivizing better health systems performance through performance-based financing. Selective technical assistance will be provided at the Central level to ensure alignment and implementation of national priorities and processes at the county level. Additionally, an important component of this activity will be to support meaningful reforms in the area of health financing including delivery of selected priorities in alignment with the MOH’s Liberia Health Equity Fund (LHEF) (Refer to Annex 2: LHEF Policy Note) to ensure quality and equitable access to health services without undue financial burden to patients.

Although there are seven health system priorities based on the World Health Organization’s building blocks, USAID/Liberia has targeted three elements for Health System Strengthening

(HSS): 1) quality of care (including diagnostic capacity); 2) finance (including public financial management and domestic resource mobilization/overall financing of the health sector); and 3) information systems and data use. These activities will be implemented in FARA (current and future) supported counties with a focus on improving malaria case detection, diagnosis, treatment and reporting in four non-FARA counties (Refer to Table 1 for county specific support).

While leadership and governance are not standalone technical priorities, it is expected that through the focus on these three technical assistance priorities that the leadership and management capacity at both the central and county levels will be improved.

USAID/Liberia will continue to advocate, with other donors and USAID funded activities at the central and county to improve supply chain and human resource policy, planning and management, and capacity in the health workforce. USAID/Liberia acknowledges that supply chain and health workforce planning and management are critical areas that impact both service delivery and health systems performance; however they will not be directly supported under this award. Capacity building for current health care workers through coaching and mentoring and targeted, minimal training will be considered under this award, specifically tied to the specific objectives outlined below.

There are three objectives of this activity:

1. Management Capacity of County Health Teams (CHTs) and Select Units at MOH strengthened to drive health system performance improvement

2. Strengthened quality of reproductive, maternal, neonatal, child and adolescent health (RMNCAH) and malaria primary health care services for improved health outcomes

3. Increased financial risk protection and health sector better financed

4. BACKGROUND

Liberia’s civil wars, which spanned from 1989 to 2003, decimated basic infrastructure, including water and sanitation, electricity, roads, education, and health services – factors that contributed to the spread of disease and premature mortality. More than a decade following the end of the conflict, Liberia continues to face significant public health challenges including health systems weaknesses that impact delivery of quality health services. Availability of skilled health workers is still low by regional standards, management capacity at all levels remains thin, and service provision in many areas is dependent on support from donors and non-governmental organization (NGO) partners. As a result, Liberia has experienced inconsistent health system performance, poor quality of care and lagging health outcomes due to inefficiencies in the health system and overreliance on fractured, donor dependent funding. With 1,072 maternal deaths for every 100,000 births1, Liberia has one of the highest maternal mortality rates in the world. The 2016 Malaria Indicator Survey also reflected a stagnant national malaria prevalence rate between 2011 and 2016 (45 percent) and highlighted a drop in the proportion of children 12-23 months in Liberia who have received all basic vaccination from 55 percent in 2013 (LDHS 2013) to 45 percent in 2016. Malaria remains a major burden and the leading cause of morbidity and

1 Liberia Demographic Health Survey (2013) mortality in Liberia. The 2013 Health Facility Survey (HFS) found that malaria accounts for about 42 percent of all clinical consultations and 44 percent of all inpatient deaths among children under five years of age, which elevates the need to intensify support in malaria programming. While there has been tremendous progress over the past 20 years, there are significant health systems issues that require continued support and solutions to accelerate progress in the health sector.

Additionally, 15% of poor households encountered catastrophic health expenditures2 compared to 8% among the rich. Forty five percent of total health expenditures are borne by households, which are much higher than the WHO 15%-20% threshold above which out-of-pocket (OOP) for health ishighly regressive (WHO, 2010). Outpatient services and over-the-counter drugs payments are the main drivers of OOP3(2014 household survey).

Current and past USAID Interventions USAID has been a steadfast supporter of Liberia’s efforts to strengthen the capacity of the health system to deliver basic services following the civil war. USAID resumed its investments in health development starting in 2004 with an initial focus on restoring basic service delivery that then expanded to support broader health system functioning at the national and county levels.

The Country Development Cooperation Strategy (CDCS) 2013 – 2018, outlined a two-tiered approach for providing both technical and financial assistance for the implementation of the MOH’s National Health Plan (2011-2021):

1. National-level investments in MOH capacity building and technical assistance for policy formulation, strategy development, and systems strengthening – including management and oversight capacity.

2. Intensive investments in three counties (Bong, Nimba, Lofa) to strengthen the health system, including expansion and improvement of facility based services, capacity building of county and local health authorities to manage resources, introduction and scale-up of global best practices, and piloting innovative interventions to generate evidence to inform national policies and strategies. This support was expanded in 2015 into additional counties with post-Ebola supplemental funding.

USAID’s partnership with Liberia has pioneered the use of an innovative government-to-government (G2G) agreement for channeling U.S. assistance for health service delivery directly through the Government of Liberia (GOL)’s health system, building the health system’s capacity in stewardship and management at the county and national levels.

Finally, Liberia became a USG President’s Malaria Initiative (PMI) focus country in FY 2008 and has received $145.8 million in cumulative funding from PMI to date. Liberia contributes to PMI’s global long-term vision of a malaria free zone in Africa, and ultimate goal of worldwide malaria eradication by 2040-2050, through scale-up of three of the four proven and highly

2 2014 Household Survey. Catastrophic health expenditures are defined as 10% of total household consumptions.

3 Payment of outpatient services mostly apply to public facilities per the 2014 household survey. 72% of households went to a public health provider while 18% visited a private for profit provider.

effective malaria prevention and treatment measures: insecticide-treated mosquito nets (ITNs);

accurate diagnosis and prompt treatment with artemisinin-based combination therapies (ACTs);

and intermittent preventive treatment of pregnant women (IPTp). To reach a critical mass with proven and highly effective malaria prevention and treatment measures and to reduce malaria burden in Liberia, PMI Liberia is scaling-up geographic coverage to strengthen malaria services delivered, improve malaria data collection, management, and dissemination to guide the national malaria control program. Therefore, this activity will play a pivotal role in supporting the PMI scale-up plan (Reference Annex 3: PMI Scale-Up Plan PowerPoint Presentation) to improve malaria case management and malaria in pregnancy interventions.

Relationship to the Government of Liberia’s Strategy This activity will contribute to the GOL’s Pro-Poor Agenda for Progress (PPAP) priorities -specifically Pillar One: Power to the People health outcomes4. The PPAP also outlines a health systems strengthening approach with a focus on five dimensions of health system performance including: Equity, Quality, Responsiveness, Efficiency and Resilience, which is also aligned to the MOH’s Investment Plan for Building a Resilient Health System (2015-2021).

All support will be in line with Liberian national and county policies, standards and county operational plans and MOH contracting-in priorities. This activity will build and capitalize on the accomplishments and lessons learned in the pre-Ebola, during and post-Ebola periods regarding systems strengthening, including from predecessor-USAID supported projects - Rebuilding Basic Health Services (RBHS) and Collaborative Support Health Systems Strengthening (CSH).

The MOH has decided to make a strategic shift using USAID funding from contracting-out delivery of health services to international NGOs to contracting-in delivery of health services directly to County Health Teams (CHT) for a more a sustainable, lower-cost model of service delivery. The MOH, in its 2016 Contracting-In Guidelines, notes that “the intent is to gradually reduce the role of NFPs [Not for Profit providers] and increase the role of CHTs in managing government facilities. CHTs may, in turn, contract directly with government health facilities for service delivery as well as with privately owned facilities (primarily non-governmental and faith-based). In all instances where contracts are used, emphasis will be placed on establishing distinct catchment populations in a given health system to ensure appropriate allocation of resources and measurable performance.” Contracting-in is an effort that contributes to and aligns with the MOH’s Decentralization Policy, which gives more resources and autonomy to CHTs. Capacity building efforts directed towards the CHTs can include complementary policy/advocacy activities working with the national government to increase CHTs’ autonomy and access to resources.

4 Health Development Outcome: By 2023, the population will experience increased access to quality healthcare delivery, effective and sustainable healthcare financing, and reduced morbidity and mortality with special focus on malaria and RMNCAH. Eight targets to be achieved by 2030: 1. Reduce maternal mortality ratio from 774 to 497 per 100,000 live births 2. Reduce Under-5 mortality ratio to 57 per 1000 live births 3. Reduce Under-5 stunting (malnutrition) from 32 percent to 22 percent 4. Reduce malaria prevalence by more than half to 20 percent 5.

Increase the share of rural population living within 5 KM of health service delivery point to 75 from 27 percent 6.

Ninety percent of public health facilities will report no stock out of essential medicines 7. Respond to 100 percent of disease outbreaks within 48 hours 8. Reduce out of pocket payments to 35 percent of total health care cost through sustainable health financing mechanism. (Pro-Poor Agenda Briefing July 2, 2018).

Additionally, the MOH adopted a Policy Recommendation on Strategic Implementation of the LHEF in December 2017 to prioritize health financing in three major areas: 1) domestic resource mobilization, 2) strategic purchasing and pooling and 3) introduction of solutions for sustainable health financing and ensuring financial protection of the poor. This activity will directly contribute to these policy recommendations.

5. OBJECTIVES

The goal of the STAIP Activity is to support delivery of efficient, responsive, equitable, and quality health services for improved access and health status for Liberians.

There are three objectives of this activity:

1. Management Capacity of County Health Teams (CHTs) and Select Units at MOH strengthened to drive health system performance improvement

2. Strengthened quality of reproductive, maternal, newborn, child, and adolescent (RMNCAH) and malaria primary health care services for improved health outcomes

3. Increased financial risk protection and better overall health sector financing

6. RESULTS FRAMEWORK

7. LINK TO CDCS

This activity will support the achievement of USAID/Liberia’s CDCS’s DO3: “Improved Health Status of Liberians”, specifically through contributions to IR 3.2: Increased Effectiveness of the Health System at National and County Levels, Sub IR 3.2.1: Increase Sustainability of Public Financing for Health, and IR 3.1: Increased Utilization of Quality RMNACH Services, and Sub IR 3.1.1: Improved Quality of Community and Facility Level Health Services. This activity will contribute to PMI goal of reducing malaria morbidity and mortality in Liberia.

8. LINKS TO OTHER ACTIVITIES

USAID implements a three-pronged approach - supporting facility level integrated health service delivery which is supported by community-based health services and buttressed by systems strengthening interventions to ensure comprehensive support for the health sector. As mentioned above, the G2G FARA mechanism focuses on strengthening decentralized service delivery for RMNCAH and malaria services.

USAID/Liberia’s Partnership for Advancing Community Services (PACS) Activity supports the implementation of the Ministry of Health Community Health Policy and activities in targeted geographic areas, including community-level service delivery strengthening. PACS additionally increases demand for, and use of health services at the facility level while ensuring community accountability of health services.

This STAIP activity would ensure strong systems to plan, manage, monitor, and support the MOH to implement its mandate, including increasing domestic resource for the health sector.

Additionally, given that this activity will support PMI scale-up in Liberia, the activity will coordinate and leverage resources from other PMI activities.

Finally, this activity will coordinate with the Global Fund, World Bank, and other development partners to maximize donor support for improved health systems performance across the country and ensure non-duplication of efforts at the central and county levels.

9. ASSUMPTIONS

It is assumed that the Government of Liberia will continue to prioritize strengthened decentralized management of health services, contracting-in, and introduction of solutions for financial risk protection and domestic resource mobilization efforts for increased resources to the health sector and improved health for citizens. Additionally, it is assumed that the GOL will resolve supply chain and human resources for health issues which affect service delivery including paying for salaries of health workers on the government payroll, and last mile delivery of commodities to health facilities and community. Finally, it is assumed that donors contributing to RMNCAH, malaria prevention and control as well as health systems strengthening in Liberia will continue their investment at the current or increased funding level.

The assumptions listed above will be revisited on an on-going basis including, but not limited to, during the Performance Management Plan (PMP) review to help determine why results are (or are not) occurring.

10. SCOPE

Activity Development Hypothesis:

Through targeted, data-driven, technical assistance to the MOH, and through the introduction of innovative health financing solutions to support sustainable financing, the performance of the health system in focus geographic areas will improve and ultimately promote delivery of equitable and quality health services for improved health outcomes.

The below sections reflect broad areas of results to be achieved by the end of the award. Each result and respective percentages reflects the expected amount of effort and budget allocations for achievement of results. For each objective and intermediate result listed below, the technical approach needs to be clearly detailed in an implementation schedule - including both short-term and long-term technical assistance solutions.

For each intermediate result the contractor will detail expected number of beneficiaries to be reached along with anticipated costs to allow cost-benefit reviews. Additionally, the contractor must propose how it will delineate and monitor implementation of Central MOH, County MOH and the contractor’s TA/responsibilities to achieve these expected results. The Contractor will indicate ties to previously implemented and complementary interventions by the MOH, USAID, and other cooperating partners, as available, in addition to building on lessons learned from previous HSS activities (USAID and non-USAID supported).

The activity must support and define key activities that will achieve the expected results below and that will drive the technical assistance approach. Proposed approaches will maximize value for money through strategic partnerships potentially with the private sector and other non-traditional partners and must integrate gender considerations into all aspects of future programming.

The activity is expected to accelerate improved decentralized management of health services with a focus on local ownership and enhanced leadership among those leading implementation.

It will provide specific expertise in a way that influences implementation and maximizes impact on beneficiaries. To this end, the Contractor will develop and be measured against county-specific work plans which target specific bottlenecks to improving CHT capacity and county health outcomes.

Specific illustrative results are listed below for each Objective and Intermediate Results (IR) that the Contractor must support achievement of per the stated timeline. The contractor can propose revised percentage achievements outlined below with sufficient justification explaining the rationale for the revised results. Direct implementation of GOL/MOH processes is not expected from the Contractor; rather the Contractor should support GOL counterparts through appropriate and targeted technical assistance to achieve the specific results listed below. Targets and indicators for out years will be developed after the first three months of the award when more accurate baselines, data measures and means of verification will be agreed upon in partnership with USAID and MOH.

OBJECTIVE 1: Management Capacity of County Health Teams and Select Units at MOH strengthened to drive health system performance improvement

IR 1.1: Improved Public Financial Management5 (10% of contractor’s effort)

Under Contracting-in, counties will receive and be reimbursed for delivery of specific results, financial reporting and required compliance with GOL practices. For the eight FARA Contracting-In counties, the Contractor will need to propose activities that will improve public financial management and reporting at the county level.

Additionally, as part of USAID’s partnership with the MOH through the FARA, a Public Financial Management Risk Assessment (PFMRAF) was conducted with an accompanying Risk Mitigation Plan that the Central MOH is currently implementing. The Contractor should propose activities that will support the implementation of the risk mitigation actions developed.

Additional assessments will take place at the county level prior to this award to identify gaps and risks identified that would require technical assistance.

Results that need to be achieved under this IR are:

● R1.1.1 Compliance with GOL/MOH PFM practices

○ SR1.1.1.1: By the end of Year 1, at least 4 out of 8 counties are in compliance with all 12 functions as per the GOL/MOH Public Financial Management Manual

● R 1.1.2 Reduction in risks identified

○ SR1.1.2.1: By the end of Year 1, at least 20% of risks identified in the PFMRAF as “high” have been resolved by the Central level MOH

○ SR 1.1.2.2: By the end of Year 1, at least 20% of risks identified in the PFMRAF as “high” have been resolved for 6 out of 8 FARA contracting-in counties

IR.1.2 Optimized Contracting-In Monitoring, Planning and Performance (5% of contractor’s effort)

In advance of this award, USAID, the Ministry of Health and the World Bank will develop a common contracting-in tool and conduct the first round of county-level assessments. All partners envision a tool that reflects competency and addresses core health systems functions.

5 Public Financial Management primarily refers to the processes, procedures and activities associated with spending public resources to include budgeting, treasury, cash management, disbursement, accounting and reporting, audit and control, and may include the financial management features of various government systems such as procurement and human resources, as well as the financial management aspects of transparency, governance and public accountability to reduce fiduciary risk.

Additionally, a third party will carry out the repeat assessment after two years (midline assessment) and at the end (end-line assessment) of the award, which will also serve as a benchmark for the contractor’s progress.

The activity is expected to provide technical assistance to respective MOH counterparts and other stakeholders to target and address gaps identified in the assessments, as per the MOH Contracting-In Guidelines. Refer to Annex 4. Contracting-In Guidelines detailing the MOH Central and County Health Teams (CHT).

● R1.2.1: Counties set and meet performance measures resulting from contracting-in assessments

○ SR 1.2.1.1:Five out of eight FARA counties are meeting performance targets as per their contracting-in MOUs by the end of Year 1.

○ SR 1.2.1.2:Eight out of eight FARA counties are meeting performance targets as per their contracting-in MOUs by the end of Year 2.

● R1.2.2: The contractor, in coordination with other technical assistance partners, , will set and meet technical assistance performance measures based on the Contracting-in assessments which are reflected in the county level work plans

○ SR 1.2.2.1:Contractor has completed 100% of TA activities as per approved county level TA workplans by the end of Year 1 in at least 4 counties

● R1.2.3: MOH scales-up lessons learned through contracting in to ensure adaptive management and robust roll-out to additional counties.

○ SR 1.2.3.1: Lessons Learned for Contracting-in Applied in at least 4 out of the 8 Contracting-in Counties by the end of Year 2

○ SR 1.2.3.2: Lessons learned for Contracting-in applied in 8 out of the 8 Contracting-in Counties by the end of Year 4

Objective 2: Strengthened quality of RMNCAH and malaria primary health care services for improved health outcomes

The IRs under this objective will support achievement of FARA contracting-in priorities and PMI National Scale-Up priorities. These IRs are also in line with the priorities of the Quality Management Unit, specifically institutionalization of country led process of the JISS and National Facility Accreditation System.

The IRs under this objective will also support implementation of key priorities to support the PMI Scale-up Plan in Montserrado, Maryland, Grand Kru and Bomi counties. As per Table 1, there are currently no partners or donors supporting these counties, thus results under IR 2 should support greater coverage of quality malaria services and improved patient outcomes.

IR 2.1 Clinical Management Capacity of Health Facilities, DHT, and CHT Strengthened to drive quality of care improvement (20% of contractor’s effort)

The activity will support the design and implementation of structured, data-driven, technical assistance at the county, district and facility level for improved delivery of quality RMNCAH, and malaria related services for improved patient outcomes utilizing existing, country-led systems and structures as a proxy measure of HSS efforts.

The continuum of care for all diseases related to RMNCAH and malaria spans functions related to prevention, treatment and diagnosis to improve patient health outcomes. The Ministry of Health and USAID have invested heavily in the Joint Integrated Supportive Supervision (JISS), therefore results under this award should build upon historical investments. Diagnostic supportive supervision is currently not included in the JISS, therefore a solution must be presented to address this critical gap until diagnostics is integrated into the JISS. The JISS system will be digitized in the near future with resources from the Global Fund and will be hosted on the DHIS 2.0 platform. As noted above, out year targets for this IR will be developed during Year 1 implementation. The contractor must employ a county-wide and district-wide approach for this IR even though the targets do not refer to 100% of facilities.

Results to be achieved under this IR are:

● R2.1.1: Institutionalization of JISS implementation6 and data use to accelerate improvement of clinical quality of care:

○ SR 2.1.1.1: By the end of Year 1, at least 60% of all health facilities assessed7 will go up by one category8 in the total cumulative scores9 in 4 of out the 8 Contracting-in counties

○ SR 2.1.1.2: By the end of Year 1, at least 60% of all health facilities assessed will go up by one category10 in the total cumulative scores11 in 2 out of the 4 non- FARA counties

6 Institutionalization of JISS includes the institutionalization of Quality Management Teams at the Facility, District, County and National levels to providing clinical coaching and mentoring for drive quality of care improvement.

7 It is expected that 100% of health facilities in each county are assessed, as per the JISS guidelines. However, of these at least 60% of health facilities should show improvement by at least one category level as per the JISS scoring system.

8 One category improvement is based on the scoring system used in the JISS from : Inadequate (0-49%) to Basic (50-69%), Basic to Intermediate (70-79%) or Intermediate to Adequate (80% or above). For facilities that start off at a baseline of adequate the improvement should be at least 95% by the end of Year 1. .

9 The data source for this information should be from the JISS conducted by the DHTs as they are required to conduct JISS of all facilities on a quarterly basis. For the FARA Contracting-In counties these improvements should be in 10 out of the 13 categories in the JISS tool including Administration, Antenatal Care, Expanded Program on Immunizations, Family Planning, Integrated Management of Newborn and Child Care, Malaria, Postpartum Care, Obstetric Care, Normal Labor and Delivery and Infection Prevention and Control. For the non-FARA counties these improvements should be in 5 out of the 13 sections specifically Administration, IPC, Malaria, IMNCI and ANC focusing on malaria services.

10 One category improvement is based on the scoring system used in the JISS from : Inadequate (0-49%) to Basic (50-69%), Basic to Intermediate (70-79%) or Intermediate to Adequate (80% or above). For facilities that start off at a baseline of adequate the improvement should be at least 95% by the end of Year 1.

11 The data source for this information should be from the JISS conducted by the DHTs as they are required to conduct JISS of all facilities on a quarterly basis. For the FARA Contracting-In counties these improvements should be in 10 out of the 13 categories in the JISS tool including Administration, Antenatal Care, Expanded Program on Immunizations, Family Planning, Integrated Management of Newborn and Child Care, Malaria, Postpartum Care, Obstetric Care, Normal Labor and Delivery and Infection Prevention and Control. For the non-FARA counties these

The below results and specific results are a subset of R2.1.1 and SR 2.1.1.1 and SR 2.1.1.2 which highlight particular questions in the JISS related to diagnosis, treatment and preventative services

- high impact practices to improve RMNCAH and malaria outcomes. The same targets above and category achievement still apply; however, particular attention should be paid to these questions under the 10 for FARA contracting-in counties or 5 non-FARA counties applicable sections in the JISS.

○ R2.1.1.2.1: Improved quality of health services as measured by adherence to existing diagnostic and treatment protocols for maternal, neonatal, child health and malaria services as per the Essential Package of Health Services and National Guidelines

○ R2.1.1.2.2: Improved quality of preventative and counselling services as measured by adherence to EPHS and National Standards for maternal, child health and malaria

● R 2.1.2: Functional Quality Assurance and Quality Control (QA/QC) systems implemented for five basic tests12conducted at the facility and county level for improved diagnostic capacity and results.

○ SR 2.1.2.1: At least 4 of out the 8 counties implementing a quality control system with improved scores from the baseline by the end of Year 1

○ SR 2.1.2.2: At least 2 of out the 4 non-FARA counties implementing a quality control system with improved scores from the baseline by the end of Year 1

○ SR 2.1.2.3: All 12 counties implementing a quality control system with improved scores from the baseline by the end of Year 3

○ SR 2.1.2.4 At least 20% increase in the total number of health facilities conducting appropriate internal quality control for all procedures as per National Guidelines in 4 out of 8 FARA-counties and 2 out of 4 non-FARA counties by the end of Year 2

○ SR 2.1.2.5: Improved turnaround time for laboratory confirmation of suspected malaria cases

○ SR 2.1.2.6: Volume of malaria cases where laboratory results influenced clinical treatment approaches

○ SR 2.1.2.7: Number of new patients enrolled in malaria treatment programs as measured by laboratory confirmation

IR 2.2 Improved malaria outcomes and health systems performance in four non-FARA counties (10%)

Given that there are no other development partners providing support to these four counties, the Contractor should propose how it will improve the delivery of malaria related services beyond the activities covered in IR 2.1 and 2.2. Activities that are under this IR should support improved malaria service delivery. Specific tasks under this activity would respond to gaps associated with improvements should be in 5 out of the 13 sections specifically Administration, IPC, Malaria, IMNCI and ANC focusing on malaria services.

12 The five basic test include Hemoglobin, Urine dipstick, HCG, Malaria microscopy and RDT, and HIV RDT health worker knowledge, focused on malaria in pregnancy, prevention messaging and case management, as well as gaps in materials such as protocols. Specific results will be jointly developed in partnership with USAID and MOH.

OBJECTIVE 3: Increased financial risk protection and better overall health sector financing

IR 3: Development and testing of Health Financing Reforms in line with the Liberia Health Equity Fund priorities to increase domestic resources for health and financial risk protection (15% of contractor’s effort)

Intervention under this IR will support Central MOH and other relevant stakeholders to strategically prioritize activities within the LHEF, guide testing and implementation of LHEF priorities including but not limited to: introduction of solutions to increase financial risk protection, and improved efficiency in current expenditures. Feasible, short-term and long-term activities should be designed and implemented to provide this support.

Results under this IR include:

● R3.1: Implement and refine FARA output-based costing system to guide incremental reforms to both FARA costs and structure as a strategic purchasing mechanism in alignment with the LHEF

● R3.2:.Test and evaluate new approaches that will contribute to increased financial risk protection and more efficient and effective health service purchasing in line with LHEF priorities

Within the context of LHEF, the contractor may introduce blended-financing approaches and must leverage current investments made by USAID specifically use of the national database currently under development with the Ministry of Women and Children’s Affairs to identify poor households that require financial protection. Additionally, for R 3.2., given that these will be new approaches that potentially require changes in legislation and policy, strategies for advocacy should be clearly identified.

CROSS-CUTTING IRs

Cross-Cutting (CC) IR 1: Improved Data Quality and Use (15% of contract’s effort)

Data quality and use is vital in order to improve both systems performance and drive improved quality of care. Results under this IR will support the Ministry of Health’s goal as outlined in the Liberian Health Information System & ICT Strategic Plan (2016-2021) (Refer to Annex 5:

Liberia HIS Strategy) which states that, by 2021, the National Health Information System of Liberia will produce the quality data and information used in support of the health system functions at all levels, with a solid governance and management structure, using appropriate information and communication technology, including data confidentiality and security, at an affordable cost to the Government of Liberia.

● CC Result (CCR) 1.1. Availability of quality, verifiable routine health information data at the facility, district, county and Central level

○ SR.1.1.1: By the end of Year 1, data quality scores improved by at least 20% in the 5 out of 8 FARA counties based on National Data Quality Review (DQR)Score13

○ SR 1.1.2: By the end of Year 1, data quality scores improved by at least 30% in the 3 out of 4 non-FARA counties based on National DQR Score for malaria indicators specifically

● CCR 1.2 Improved review, analysis and use of verified data for decision-making at county and central level

○ SR 1.2.1: Quarterly review meetings institutionalized14 in all counties

● CCR 1.3. Improved planning and targeted supervision based analysis and review of data from the various health information sub-systems

Specific health information subsystems that support data for decision-making at the central MOH and county health teams (R1.1.4) includes District Health Information System (DHIS) 2.0 for routine health information, integrated disease surveillance and reporting for priority and notifiable diseases, logistics management information systems (electronic and or paper-based) for supply chain management, integrated Human Resources Information Systems (iHRIS), laboratory information system. JISS data review and data quality will also fall under this IR.

CC IR 2: Strengthened Performance Based Financing (PBF) Operations to Drive and Incentivize Central and County Level Systems Performance and Quality of Care (15% of contract’s effort)

The MOH implements a PBF approach to reimburse achievement of both select health service delivery and health systems strengthening indicators as outlined by the MOH PBF Manual (Refer to Annex 6: PBF Manual). The standard PBF indicators were developed with support from USAID and agreed to by USAID and the World Bank. At present, the MOH is implementing PBF with the same indicators but through different structures in the World Bank and FARA counties. The World Bank is launching implementation research around PBF with buy-in from all partners to better understand options for maximizing performance. The contractor must be an active, technical participant in discussions and reviews of the PBF implementation research with the ultimate goal of establishing a single, evidenced-based, high-impact PBF scheme for nationwide roll-out.

Implementation of PBF and the related implementation research will inform implementation of LHEF reforms and the contractor is expected to ensure a routine feedback loop between PBF and LHEF discussions.

13 This is a national tool applied annually, however, the contractor will be responsible to develop/adapt a tool and process to decentralize data quality review and improvement. The means of verification for this improvement will be revised during Year 1 for implementation and use in Year 2. The baseline for the DQR is based on the July 2018 report which reviewed data for January-December 2016.

14 Institutionalization for this result includes agreement of standard indicators to be reviewed, presentation template and format, and documentation of meeting minutes including an action plan and guidance to improve gaps identified during review meeting that should be addressed prior to the next meeting.

USAID expects the contractor will introduce and test PBF in the implementation of activities at the county level in the 8 FARA counties, in addition to the routine GoL system. Evidence from this experience will inform the national PBF scheme but should be aimed at achieving the health systems objectives identified in this SOO. Innovation is encouraged to drive results described in IR 1 and 2. A minimum of 10 percent of this award will be utilized for PBF reimbursement to the county health teams. The contractor should propose some initial thoughts on revisions to the currently PBF model to incentivize better quality of care at the facility level and management at the county health team levels including the percentage of primary health care facilities that would implement PBF for quality improvement. USAID already has a G2G agreement with the Government of Liberia to provide funding to public sector facilities under the Ministry of Health.

However, the contractor must propose an implementation and management model for PBF reimbursement under this award.

Specific results under this IR include:

● CCR 2.1: Nationwide PBF scheme in place to drive quality and access of critical health services.

● CCR 2.2:Innovative approaches to PBF tested and verified at the county level to improve performance

CC IR 3: Implementation of responsive technical assistance (up to $2 million and up to 10% of contract’s LOE)

Two million dollars of the award, and approximately 10% of the contractor’s level of effort, will be set aside for adaptive, responsive technical assistance to address gaps identified at both Central and county level in meeting their functional responsibilities. This CC IR will support achievement of IRs 1, 2 and 3. Half of this responsive technical assistance (RTA) funding (up to $1 million and up to 5% of contract’s LOE) will be dedicated to supporting quality improvement at health facilities based on JISS findings to improve JISS scores while the remaining half should be used to support responsive general health systems’ emerging needs.

The intent of having responsive technical assistance is to allow the contractor to adapt and be flexible to emerging needs. The contractor should outline key results and technical approaches to address IRs 1, 2, 3 and all Cross-Cutting IRs. However, given the need to provide appropriate, evidence-based effective technical assistance, USAID recognizes that throughout the life of the award, there may be new needs not originally identified or proposed by the contractor.

Therefore, this Cross-Cutting IR allows adaptability and flexibility for the contractor to support required technical assistance needs. This means that during the course of implementation, the Contractor must identify gaps and propose RTA that ensures accountability by all parties including MOH and recipients of the TA, technical delivery and quality control of all products delivered under this mechanism. RTA will be utilized, if needed, to address gaps that arise during the course of implementation that pose a significant threat to successful activity outcomes. These technical assistance needs will most likely arise through the contracting-in assessments and county work planning process. There will be an emphasis on implementation of malaria specific technical assistance. It is expected that RTA under this mechanism will be catalytic to drive improved service delivery, management and accountability with the ultimate goal of improved health outcomes in select geographic areas.

Requests under the RTA component must be pre-approved by USAID with concurrence from the MOH and observers from the donor community, when applicable, to maximize external investments to the health sector and ensure streamlined technical assistance for unified support to the MOH with stronger delivery and accountability of technical assistance provided under this activity. Justification for any RTA to strengthen quality of care improvements need to be fully supported by JISS documentation and a feedback plan that directly links the required support to the criteria outlined in the JISS.

Responsive technical assistance under this Cross-Cutting IR may include short-term technical assistance, long-term technical assistance, and purchase of limited supplies and/or equipment to support better systems performance of improved quality of care. These activities can be directly implemented by the contractor, sub-contractors, or other local, regional or international partner/organizations. The contractor is directly responsible to manage the request for responsive technical assistance needs, seeking clearance from USAID and directly funding and managing the responsive technical assistance activities. It should be noted that whatever activities are implemented under this Cross-cutting IR should directly contribute to another IR within the Results Framework.

The RTA may be used to support interventions that contribute to the achievement of all of FARA and PMI activity purposes and may include but are not limited to some of the following illustrative examples:

● Standing up new technical systems or processes identified by USAID, FARA, MOH Central or County Health Teams;

● Supporting CHT access to resources – technical or physical - to implement recommendations to strengthen systems that permit and/or encourage better health system performance and quality of care improvement;

● Supporting MOH efforts to strengthen its institutional framework to tackle public financial management, health financing reform, performance based financing reform, data quality improvement and use, quality of care improvement (including diagnostics), or malaria specific TA

● Expanding the number or type of technical assistance interventions and/or training activities provided by the contractor;

● Developing sectoral monitoring, analysis, and assessments;

● Supporting the National Malaria Control Program to conduct therapeutic drug efficacy monitoring, operational research, and developing their capacity for data analysis, writing reports. Abstracts, and manuscripts for presentation to various scientific conferences locally and internationally.

JISS Illustrative examples:

● Purchasing wash basin and chlorine to support improved IPC compliance

● Minor repairs to a facility that are not major renovations i.e. replacement of a broken window that affects IPC

Results under this IR includes:

● CCR 3.1: Development of Standard Operating Procedures to guide management of RTA Approaches

● CCR 3.2: Funding and provision of targeted TA to respond to identified gaps

11. SUCCESS

Success will be measured through achievement of clear targets that respond directly to the results as per Section 11 scope of this SOO.

Additionally, USAID/Liberia will tie reimbursement of fees directly to achievement of:

1. At least 20% increase in overall capacity assessment scores from baseline to midline and a minimum of an additional ten percent increase in overall capacity assessment scores from mid-line to end-line capacity assessments. This measurement will be verified by the MOH and USAID. (Objective 1)

2. Increased proportion of suspected malaria cases tested with RDTs or microscopy (malaria test rate) and treated: Annual increase to be proposed by the Contractor after the baseline has been determined. This measurement will be verified through a third party providing support and verification to FARA. (Objectives 2)

3. Decreased facility maternal mortality ratio in 3 FARA contracting-in counties by 40% by the end of the award (Objective 2). This measurement will be verified by a third party maternal death facility audit.

4. Decreased average per capita out-of-pocket expenditure in pilot area by 50% by the end of the pilot period (Objective 3)

The contractor will work closely with an external contractor to be hired by USAID during the annual performance audits to verify achievement and reimbursement for the above.

12. SPECIAL CONSIDERATION

12.1 OPERATING CONSTRAINTS

Given that this activity does not provide health services, if there are delays in payment of health care workers, labor strikes, stock out of essential medicines, this could impact service delivery and affect quality of care improvement approaches and therefore the ability of the contractor to provide technical assistance. Additionally, significant shifts in MOH leadership, political/economic instability, GOL policies or FARA priorities could be potential constraints for this activity.

12. 2 COLLABORATION, LEARNING AND ADAPTATION

USAID seeks to promote learning across stakeholders involved in the implementation of this activity through Collaborating, Learning, and Adapting (CLA). Activity learning is intended to benefit all stakeholders.

CLA Objectives:

a. Generate Knowledge. The Contractor will generate new knowledge and evidence around learning questions identified together with USAID and other stakeholders, as well as questions that may emerge during the course of implementation. In filling these knowledge and evidence gaps, the contractor will provide reporting, data, analysis, and gather partners for inclusive reviews of the activity goals and results.

b. Share Knowledge. The Contractor will increase knowledge-sharing with stakeholders, including local organizations, national and local level MOH, sectoral experts, donors, regional and international organizations, and others through communities of practice to encourage more widespread learning across teams, mechanisms, and sectors. The contractor will work together within a learning network to share information with implementing partners of other USAID activities, such as local stakeholders and other development partners. The contractor will convene forums to share knowledge and will also use existing forums as available. The contractor must attend and participate in these meeting. This activity will support the provision of case studies, lessons learned, success stories, and learning events to share among partners and stakeholders working in health systems strengthening. This includes working with USAID, MOH, CSOs, domestic and foreign academia, and other partners to identify lessons learned from previous and ongoing sector wide programming, including the World Bank Funded Performance Based Financing and TA contractor.

c. Incorporate Agile and Adaptive Processes. The contractor will develop adaptive management and implementation processes to allow course correction to respond to unintended effects, changing/emerging realities, and priorities. Together with USAID, the activity’s work plan, quarterly reports, and periodic progress review meetings will provide a forum for an adaptive approach to change course or make corrections based on lessons learned and evolving country context.

Additionally, activity designs and annual work plans will allow for responding to windows of opportunity which include responding to national dialogues initiated by the government.

Implementers will stay abreast with political and economic shifts and recognize when there are windows of opportunity and moments of political and social change when reform is more likely to take root. The contractor will prioritize activities together with the COR during work planning and review the prioritization during the quarterly reporting period.