95332418Q0123_0_US_final_signed_by_CO.pdf

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

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95332418Q0123

TABLE OF CONTENTS:

Listing of Incorporated Purchase Requisitions Section B - Supplies or Services and Prices/Costs Section C - Description/Specifications/Work Statement Section D - Packaging and Marking Section E - Inspection and Acceptance Terms Section F - Delivery or Performance Section G - Contract Administration Data Section H - Special Contract Requirements Section I - Contract Clauses Section J - List of Documents, Exhibits, and other Attachments Section K - Representations, Certifications, and Other Statements of Offerors Section L - Instructions, Conditions and Notices to Offerors Section M - Evaluation Factors for Award

Listing of Incorporated Purchase Requisitions

Incorporated Purchase Requisition Numbers:

DCO-PR-18-0297

Section B - Supplies or Services and Prices/Costs

Item Number Base Item Number

Supplies/Services Quantity Unit

0001 Lesotho: Reducing the Burden of HIV/AIDS and Health Systems

Strengthening requirement

1 USD

Contract Type:Time and Materials Unit Price

Other Direct Costs Extended Price

Description:

Purchase Requisitions DCO-PR-18-0297

IDC Type: Not Applicable NAICS Code: 541611 Administrative Management and General Management Co...

Supplies/Services Quantity Unit

0002 Lesotho: Reducing the Burden of HIV/AIDS and Health Systems

Strengthening requirement

1 USD

Contract Type:Time and Materials Unit Price

Other Direct Costs Extended Price

Description:

Purchase Requisitions DCO-PR-18-0297

Supplies/Services Quantity Unit

1001 0001 OY 1 Lesotho: Reducing the Burden of HIV/AIDS and Health

Systems Strengthening requirement

1 USD

Contract Type:Time and Materials Unit Price

Other Direct Costs Extended Price

Description:

Purchase Requisitions

Option: 1 Option Time Date: 7/1/19 Option Time Duration: 365 Option Time Units: Days

Supplies/Services Quantity Unit

2001 0001 OY 2 Lesotho: Reducing the Burden of HIV/AIDS and Health

Systems Strengthening requirement

1 USD

Contract Type:Time and Materials Unit Price

Other Direct Costs Extended Price

Description:

Purchase Requisitions

Option: 2 Option Time Date: 7/1/20 Option Time Duration: 364 Option Time Units: Days

Supplies/Services Quantity Unit

3001 0001 OY 3 Lesotho: Reducing the Burden of HIV/AIDS and Health

Systems Strengthening requirement

1 USD

Contract Type:Time and Materials Unit Price

Other Direct Costs Extended Price

Description:

Purchase Requisitions

Option: 3 Option Time Date: 7/1/21 Option Time Duration: 364 Option Time Units: Days

Supplies/Services Quantity Unit

4001 0001 OY 4 Lesotho: Reducing the Burden of HIV/AIDS and Health

Systems Strengthening requirement

1 USD

Contract Type:Time and Materials Unit Price

Other Direct Costs Extended Price

Description:

Purchase Requisitions

Option: 4 Option Time Date: 7/1/22 Option Time Duration: 364

Option Time Units: Days

Clauses incorporated by reference

None

Clauses incorporated by full text

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

B.1 PURPOSE

The purpose of the contract is procure services for the Lesotho: Reducing the Burden of HIV/AIDS and Health Systems Strengthening requirement. This is a combined synopsis/solicitation for commercial items prepared in accordance with Subpart 12.6, as supplemented with additional information included. The solicitation document and incorporated provisions and clauses are those in effect through Federal Acquisition Circular 2005-99.

NOTE: The following document has been automatically generated by an electronic system. Some errors in spacing, formatting and punctuation may have occurred throughout the document and are out of our control.

B.2 CONTRACT TYPE

This is a Time-and-Material(T&M) contract. For the consideration set forth in the contract, the Contractor shall provide the del iverables described in Section F and comply with all contract's requirements.

B.3 SCHEDULE OF SERVICES AND PAYMENT

The Total Estimated Price of this contract is $ TBD. The maximum dollar amount awarded to the contractor cannot exceed the Total NTE Price.

ITEM

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES

QUANTITY UNIT UNIT PRICE AMOUNT

0001 Lesotho: Reducing the Burden of HIV/AIDS and Health Systems Strengthening requirement

Contract Period: Base 9 months

NTE $TBD

POP Begin: TBD

POP End: TBD

0001A Direct Labor Hours See Table of Labor Rates and Categories

Below

$TBD

0001B Other Direct Costs 1.00 Lot $TBD $TBD

1001 Lesotho: Reducing the Burden of HIV/AIDS and Health Systems Strengthening requirement Contract Period: Option One, 12 months

POP Begin: TBD

POP End: TBD

NTE $TBD

1001A Direct Labor Hours See Table of Labor Rates and Categories

Below

$TBD

1001B Other Direct Costs 1.00 Lot $TBD $TBD

2001 Lesotho: Reducing the Burden of HIV/AIDS and Health Systems Strengthening requirement Contract Period: Option Two, 12 months

POP Begin: TBD

POP End: TBD

NTE $TBD

2001A Direct Labor Hours See Table of Labor Rates and Categories

Below

$TBD

2001B Other Direct Costs 1.00 Lot $TBD $TBD

3001 Lesotho: Reducing the Burden of HIV/AIDS and Health Systems Strengthening requirement Contract Period: Option Three, 12 months

NTE $TBD

POP Begin: TBD

POP End: TBD

3001A Direct Labor Hours See Table of Labor Rates and Categories

Below

$TBD

3001B Other Direct Costs 1.00 Lot $TBD $TBD

4001 Lesotho: Reducing the Burden of HIV/AIDS and Health Systems Strengthening requirement Contract Period: Option Four, 12 months

POP Begin: TBD

POP End: TBD

NTE $TBD

4001A Direct Labor Hours See Table of Labor Rates and Categories

Below

$TBD

4001B Other Direct Costs 1.00 Lot $TBD $TBD

TOTAL NTE $TBD

The Contractor shall furnish all personnel, facilities, equipment, supplies, transportation, and other services required to provide services to the MCC in accordance with Section C, Statement of Work, and the terms and conditions contained herein. The Total Contract Price includes labor and other direct costs to perform all required services.

LABOR RATES

CLINs Labor Category Labor Rates Base 9 months

Labor Rates

Option Year 1

Labor Rates

Option Year 2

Labor Rates

Option Year 3

Labor Rates

Option Year 4

0001 Team Leader Reducing Burden of HIV/AIDS Specialists* - seven people

TBD TBD TBD TBD TBD

1001 Team Leader Reducing Burden of HIV/AIDS Specialists - seven people

TBD TBD TBD TBD TBD

2001 Team Leader Reducing Burden of HIV/AIDS Specialists - seven people

TBD TBD TBD TBD TBD

3001 Team Leader Reducing Burden of HIV/AIDS Specialists - seven people

TBD TBD TBD TBD TBD

4001 Team Leader Reducing Burden of HIV/AIDS Specialists - seven people

TBD TBD TBD TBD TBD

* The term "Reducing Burden of HIV/AIDS" specialist is a broad term to indicate a specialist with skills, experience and expertise listed in Section C, TABLE 2: Qualifications/experience that the Team Should Cover. The offeror should replace the title "Reducing Burden of HIV/AIDS" Specialist with a position title that best reflects the skills, experience or expertise held by the consultant proposed

TOTAL LABOR HOURS

Estimated LOE Base Period 9/2018 - 6/2019

OY One 6/2019 - 6

/2020

OY Two 6/2020 - 6

/2021

OY Three 6/2021 - 6

/2022

OY Four 6/2022 - 6

/2023

TOTAL

Consultant 1 - Team Leader 500 3,441

Consultant 2 - Specialist 500 3,441

Consultant 3 - Specialist 400 2,752

Consultant 4 - Specialist 350 2,408

Consultant 5 - Specialist 220 1,514

Consultant 6 - Specialist 220 1,514

Consultant 7 - Specialist 400 2,752

Consultant 8 - Specialist 350 2,408

TOTAL 2,940 4,410 4,366 4,322 4,193 20,231

The contractor should propose well-functioning team to successfully implement the SOW. The total LOE hours for each labor categoryshall not be exceeded.

B.4 ADDITIONAL LABOR CATEGORIES AND COUNTRIES

During the performance of this contract, it may become desirable to add new labor categories to Section B. In such cases, the Government or the Contractor may identify additional labor categories and the Contractor may propose additional labor categories and rates.

In addition, during the performance of this contract, it may became necessary to add other MCC Compact-Eligible countries.

Section C - Description/Specifications/Work Statement

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

ACRONYMS AND ABBREVIATIONS

Acronym, Abbreviation Definition

CA Constraints Analysis

CAP Constraints Analysis Panel

COR Contracting Officer Representative

CPARS Contractor Performance Assessment Rating System

CT Country Team

GDP Gross Domestic Product

GoL Government of Lesotho

IEA Implementing Entity Agreements

IM Investment Memo

IMC Investment Management Committee

MCA Millennium Challenge Account, the accountable entity

MCC Millennium Challenge Corporation

MCHN Maternal Child Health and Nutrition

PII Personally Identifiable Information

PM Project Monitor

PPAM Project Proposal Assessment Memo

QCP Quality Control Plan

RFP Request for Proposals

RFQ Request for Quotations

RMS Recruitment Management System

SAM System for Award Management

TBD To Be Determined

WASH Water, Sanitation and Hygiene

C.1 INTRODUCTION

The Millennium Challenge Corporation (MCC) is a U.S. Government corporation formed to help low income and low middle income countries reduce poverty through the promotion of sustainable economic growth. MCC operates on the principle that aid is most effective when it strengthens good governance, economic freedom and investments in people. MCC awards multi-year grants known as "Compacts" to partner countries that meet its selection criteria and propose programs that address their constraints to economic growth. Once developed and agreed, MCC compacts must be implemented by those partner countries within terms of not more than five years.

Through this solicitation, MCC seeks to procure due diligence services to support a response to the Poor Health related to HIVAIDS constraint to economic growth identified in Lesotho Constraint's Analysis. These due diligence services are specifically intended to support MCC's Human and Community Development practice group and Gender and Social inclusion practice group in a range of activities during compact development and implementation.

C.2 BACKGROUND

Lesotho Compact Program Background

MCC and the government of Lesotho (GOL) initially began second compact development in June 2014, and established the Lesotho Millennium Development Agency (LMDA) compact development team in August 2014. From 2014-2015, MCC and the LMDA team undertook a number of initial compact studies to objectively prioritize the binding constraints to private-led investment and entrepreneurship in Lesotho. The Constraints Analysis (CA), Initial Social and Gender Assessment, and Investment Opportunities Analysis, known collectively as the Foundational Studies for Lesotho, were completed in December 2014. In December 2015, MCC's Board deferred its vote on Lesotho's eligibility in order to give the government time to respond to political instability. The Board deferred its vote again in 2016, effectively placing compact development on a two year hiatus until reselection in December 2017.

Following reselection, MCC's Country Team reviewed the Foundational Studies and completed MCC's standard set of tests of those constraints considered binding in 2015: health, skills, land, and government regulatory and legal frameworks.

During the February 2018 Mission, the MCC Country Team (CT) sought to validate the binding constraints to growth in Lesotho that were identified during the first phase of compact II development in 2015. The CT presented their desk research and held consultations with the Constraints Analysis Panel (CAP), made up of representatives from the Government of Lesotho (GOL) and academia. Through these consultations, it became clear that the binding constraints had evolved since 2015. Furthermore, the CAP had concerns about job creation in Lesotho. The CT and the LMDA held a number of workshops and meetings with stakeholders to further investigate and validate the constraints, including in sectors with job creation potential, using the data available and weighing appropriately the anecdotal evidence presented by the CAP and stakeholders. The CT presented two binding constraints (related to health and government dysfunction) and two non-binding constraints (access to non-reputational credit and road infrastructure) to the CAP panel. The CAP panel agreed with the evidence provided for these constraints, and the CT agreed to move forward with further testing of these constraints.

Following further analysis and clarity sought by MCC's Department of Policy and Evaluation, the MCC that the inhibiting factors to private sector growth in Lesotho could be best described by two binding constraints: Poor Health Primarily Related to HIV/AIDS and Ineffectiveness of Policy Planning, Coordination and Execution. The latter embodies both absence of planning and coordination between the public and private sector for efficient public investment, and poor government performance in executing plans. These were later validated by the CAP, the CAP indicated agreement with the economist's findings and the revised constraints. The scope of work in this RFP relates to the first constraint, Poor Health Primarily Related to HIV/AIDS. Summary of the critical evidence around the health constraint identified through the CA is below:

Poor Health Primarily Related to HIV/AIDS:

• The burden of disease on working age individuals in Lesotho is the highest in the world. This is best illustrated using Disability-Adjusted Life Years in Lesotho, which are primarily driven by HIV/AIDS.

• Among 15-49 year olds, Lesotho lost 80,000 DALYs per 100,000 individuals in 2016, two-thirds greater than the average of 48,000 per 100,000 individuals in Southern Africa, and 150 percent greater than the average of 31,500 per 100,000 in Sub-Saharan Africa overall.

• The HIV/AIDS infection rate remains high despite progress by other countries in the region to reduce their rates, and the gap continues to increase over time.

• The analysis shows that this disease burden substantially reduces labor productivity, discourages investments by firms that would create jobs, and creates large direct costs for the government and households through health care expenditures and care for those dependents whose family members have died as a result of the disease.

• The disease burden is different across gender, age and occupation: HIV prevalence rates are 30% for women vs.

21% for men; 17% for women vs. 6% for men 20-24 years; 50% for women 35-39 years; 49% for men 40-44;

55% for women in garment factories; 38% for women domestic workers.

Anecdotal evidence for this constraint is the textile industry in Lesotho. By 2006 the HIV pandemic was beginning to devastate the textile industry, as HIV-infected workers developed full-blown AIDS. The Lesotho Textile Exporters Association notes that absenteeism due to HIV/AIDS increased to about 5%, productivity in the factories declined, and the constant cycle of AIDS-related deaths and funerals significantly affected the industry. In response, the industry started Apparel Lesotho Alliance to Fight AIDS (ALAFA). Its interventions contributed to a decline in absenteeism to less than 2% and a 10% increase in productivity. However, because of a lack of financing and government support, ALAFA ceased operations in 2014.

Subsequently, more than half (27) of the member factories of the Lesotho Textile Exporters Association and the Lesotho Industrial Employers Association have retained these clinics, given their positive impact on productivity. This is a clear indication that the private sector is attempting to circumvent the constraint, one of the indications that it is a binding constraint on growth.

Lesotho Compact Timeline

Given the existing analysis and the to-date strong commitment and involvement of the GOL, MCC is taking an aggressive timeline to completing compact development. Following the root cause analysis and concept note drafting process, the team anticipates presenting an opportunity memo to the IMC in July 2018. By the end of calendar year 2018, we expect to have a project proposal assessment memo ready for review, and an investment memo by November 2019. Our most aggressive schedule sets a target date for compact negotiations in early 2020, with a presentation of the compact to MCC's Board at the March 2020 Board meeting, and signing ceremony shortly thereafter. This timeline does assume continued progress from the Government of Lesotho on both critical political reforms and sustained attention to maintenance of first compact investments.

Compact Development Timeline

Compact Development Phase Milestone Date

Phase 1. Preliminary Analysis January 2018 - April 2018

Recruitment of GOL compact development team and MCC

CTL

Completed March 2018

Findings of CA Completed March 2018

CA Peer Review Completed April 2018

GOL approval of CA binding constraints May 2018

CA IMC April 2018

Phase II. Problem Diagnosis May 2018-July 2018

Root Cause Analysis Workshops May 2018

Concept Note submission by GOL to MCC July 2018

Award key due diligence contracts September - December 2018

*609(g) request and Agreement September - December 2018

Opportunity Memo August 2018

Phase III. Project Definition July 2018– December 2018

Project Assessment December 2018 – November 2019

Project Proposal Assessment Memo December 2018

*Mobilize 609(g) consultants February 2019 – April 2019 (6 months to IM)

Investment Memo November 2019

Compact Negotiations/Signing November 2019 - March 2020

Negotiations November-December 2019

Board decision and compact signing April 2020

Prepare Entry into Force May 2020-May 2021 (12 months)

Situational Analysis of the HIV/AIDS in Lesotho

1. Historical development of the Lesotho HIV/AIDS situation:

Lesotho has over 2.2 million inhabitants [1], 52% are female and 48% are male. About 72% of people are sparsely distributed in rural mountainous areas, while the remainder of the population is concentrated in urban centers such as Maseru and Leribe that offer limited opportunities to work for low wages under difficult conditions in the garment industry and as informal domestic workers [2]. In 2016, life expectancy at birth was 54 years, 2 to 6 years less compared to the neighboring countries (Swaziland: 56.7 years; Zimbabwe: 60.3 years; Zambia: 61.3 years) with similar HIV epidemics.

As of 2016, Lesotho's HIV prevalence rate was at a staggering 25 percent among the 15-49 years age group, the second highest prevalence in the world. [3] Close to 330,300 people are living with HIV and 21,000 people were newly infected in 2016. [4] HIV is primarily transmitted through unprotected heterosexual intercourse, accounting for 80% of new infections in 2014. [5] Working age population groups, including sex workers, factory workers, prison inmates, pregnant women, and adolescent girls and boys are predominantly infected. There is a relatively high rate of sexual concurrency (25%) compared to average (10%) in the rest of Southern Africa Development Community. [6]

As this large group of working adults have become sick due to AIDS-related symptoms and unable to partake in economic activities, they have dramatically impacted productivity and disrupted the country's social fabric and support systems.

In June 2016, Lesotho was the first country [7] to implement World Health Organization (WHO) 'Test and Start' or 'Test and Treat' or 'Treat All Living-people- with HIV' guidance to augment Antiretroviral therapy (ART) services and save lives. Despite that achievement, Lesotho still has one of the highest HIV prevalence rate in the world and its response to the epidemic is reported as inadequate with regard to addressing existing gaps in care and treatment, and tackling the main drivers of the epidemic that has far reaching implications for its economic growth and the achievement of the Sustainable Development Goals.

2. Health Systems:

The HIV/AIDS prevalence rate only provides a glimpse at the state of the Lesotho's health system. A closer look at the child health indicators [8,9] show a grim picture when compared to global data and few neighboring countries. In the past two decades, the under 5 mortality rate in sub-Saharan Africa dropped by almost half, from 155 deaths per 1,000 live births in 2000 to 78.3 deaths in 2016. In Lesotho, the same rate only slightly reduced from 110.3 deaths per 1,000 live births in 2000 to

94.5 in 2016. In the same way, other child health indicators have remained poor compared to countries in the region: in 2016, infant mortality rate was 72.4; neonatal mortality rate was 40; prevalence data for stunting and wasting for Under 5 children was 33.2 percent and 2.8 percent respectively. The same indicators for Zimbabwe and Swaziland were significantly lower than Lesotho's.

Maternal health indicators were almost on par with neighboring countries. But variations still existed. Maternal mortality rate was 487 deaths per 100,000 live births (2015), an indication that emergency obstetric care as well as adequate prenatal and postnatal care services remained a challenge for women. In addition, only 33 percent of a cohort of women surveyed would survive to age 65 [10,11]. The global average was 72.75 percent surviving to 65 years, while 52 percent and 49 percent survived until age 65 in Zambia and Zimbabwe respectively. The uncovered variations in data between urban and rural settings were further indicative of challenges in accessing health services. And women and children were disproportionately affected.

Despite a steep increase in funding to make Antiretroviral Therapy (ART) available, 9,900 AIDS-related deaths were recorded in 2016. HIV/AIDS remained the leading cause of deaths, especially among the working age subpopulation group, with more women being affected as compared to men. The introduction of ART has reduced the number of deaths as compared to previous years, but many people living with HIV are not reached with the right information on how to remain uninfected and or to access the ART. Only 38.5 percent of young females reported to have a comprehensive correct knowledge about HIV-defined by the World Bank as the ability to recall 2 preventative methods and reject 3 misconceptions. The same indicator for young males was a mere 30.9 percent. This data suggests young people do not have sufficient knowledge to prevent HIV infection.

The Government of Lesotho (GoL) has been supportive of the Presidential Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund through targeted investments in the health sector and the fight against HIV/AIDS in particular. While the health expenditure piece of the national budget has remained steady over the past years (11-12 percent of national budget) [ 12,13], the HIV allocation of the health budget has increased to 16% in 2016/17, from 10% in 2014/15. This HIV portion of the Lesotho Ministry of Health (LMOH) was mainly focused on treating and caring for People Living with HIV (PLHIV).

3. Human Resources for Health and Decentralization [14,15,16,17]:

Lesotho has 0.5 doctors and 6.2 nurses for every 10,000 people. These numbers are below WHO standard of 2.4 doctors and

10.9 nurses per 10,000. Lesotho is also experiencing major challenges in delivering health services associated with the 'start and treat' WHO guidance that requires that any patient that tests positive for HIV to be immediately put on ARV. The substantial increase in the HIV/AIDS component of the health budget demonstrates that the country's leadership understands the threat that HIV/AIDS continues to pose and the imperative to continue to garner resources and eliminate the epidemic. In practice, however, that understanding did not fully translate into policies' implementation that reflected the adoption of the 2005-2025 Ministry of Health and Social Welfare Strategy Plan on Human Resources Development and Decentralization designed to 'reduce the incidence and impact of poverty through expansionary macroeconomic policies designed to foster growth in production and employment, and through public sector performance improvement achieved through a more effective allocation of resources towards activities with the highest impact on poverty alleviation for fighting HIV/AIDS'. In theory, the decentralization of health services was meant to be cornerstone and the central approach to the new Strategy.

Acknowledging the impact of HIV/AIDS and its responsibility for the near collapse of the health system, the new Strategy focused on the introduction of the Community Health Worker program and created Post, Village and Filter Clinics throughout the country to provide primary care in the most cost-effective and equitable manner. Another key aspect of that Strategy Plan was call for rationalizing health sector labor supply, improving retention, and appropriately training Human Resources to staff district health centers that would ensure smooth primary healthcare services delivery. The lack of leadership and capacity in the Ministry of Health (MoH) resulted in poor health systems performance. Frequent personnel changes in the MoH exacerbated an already inefficient system and rendered the decentralization process sub-optimal.

The Government of Lesotho (GOL) abolished user fees in public hospitals in 2008. This has contributed to significant uptake and demand for healthcare services and added even more pressure on the healthcare system. The GOL is the largest healthcare provider in the country, operating 110 primary healthcare centers and 11 general hospitals. The Christian Health Alliance of Lesotho operates 61 primary healthcare centers and eight general hospitals, and is mainly financed by Lesotho's MoH.

While these hospitals are striving to serve the population of Lesotho, previous data indicated that for HIV/AIDS interventions to be effective, at-risk populations ought to be targeted where they live and or work.

4. The ALAFA Model [18,19,20,21]:

The Apparel Lesotho Alliance to Fight AIDS (ALAFA) intervention sought to reach women employed in the garment industry and was successful, despite its short lifespan. ALAFA represented a consortium of employers in the garment industry, civil society, and the GOL. ALAFA aimed to reach 46,000 women working in textile factories through funding provided by UK's DFID. Started in 2006, ALAFA received numerous awards for developing and implementing a successful public-private industry-wide program that has delivered education and prevention, voluntary testing and counseling, and management of AIDS for HIV-positive workers and their spouses. Had ALAFA not intervened, the apparel industry would have crumbled due to loss of workers and related auxiliary costs to absenteeism, hospital fees and funerals. HSLP, the consultants supporting ALAFA, estimated that 1,850 lives were saved year in the industry through ALFA.

Following DFID's funding cut, the ALAFA program ceased its activities in 2014, and similar initiatives have unfortunately never been pursued. Through ALFA it became clear that poverty and inequality were the root causes of the high HIV prevalence among women working in factories.

5. An Ambitious roadmap to end the AIDS epidemic:

Despite Lesotho's stigma and discrimination against People Living with HIV [22], donors' support has focused on getting people tested, linking them to treatment and care, and providing antiretroviral drugs to those testing positive. The 90-90-90 target is an attempt to get the HIV epidemic under control by testing, starting HIV positive patients on ARVs and ensuring they are to successfully suppress the virus. The importance of the test and start scheme was: (a) to identify people early on in their infection and (b) to dramatically prolong their life and productivity, and (c) prevent further infections.

In June 2016, Lesotho was the first country to adopt the 'Test and Start' WHO's new guidance. Out of the 330,000 People Living with HIV, 77 percent knew their HIV status, 90 percent of those of knew their HIV status were put on ARVs, and 88 percent of that group have achieved viral suppression. Lesotho is one of the few countries on track to reach the 90-90-90 target by 2020 [23]. But PEPFAR had identified existing programmatic gaps, including low Early Infant Diagnosis (EID) coverage for HIV exposed infants aged <2 months; sub-optimal cohort monitoring and tracking of aging-out of Children Living with HIV on treatment; inadequate capacity of service providers in the provision of adolescent-friendly health services; and management of pediatric treatment failure, identifying cases, initiating treatment and retaining patients. PEPFAR' COP 2017 for Lesotho recommended closing identified gaps and saturating districts with ARVs and supporting capacity building for nursing, procurement and training surveillance health personnel.

6. A menacing tuberculosis co-infection:

Lesotho's HIV/AIDS crisis is compounded by increasing level of tuberculosis infections and low tuberculosis treatment coverage [24,25]. Lesotho treatment success rate stagnated at 70 percent. TB treatment coverage reached a paltry 46 percent, the lowest coverage in the sub-region.

7. Intersecting Economic, Social, and Cultural Drivers of HIV

Two key dimensions have emerged as drivers of the high rate of new infections in Lesotho: economic deprivation and social norms. These root causes intersect, and each one has several sub-dimensions. The first dimension relates to the lack of economic opportunity in rural and urban Lesotho—high unemployment, declining agricultural productivity, and high poverty rates. These conditions are compounded by gender norms, which create particular vulnerabilities for women. In Lesotho, while gender gaps in education favor women, access to physical assets and economic resources favor men. Certain remaining laws and low implementation of laws aimed at gender equality also make it more difficult for women and girls to participate in economic activity, e.g. inheritance law, the primary means of acquiring and distributing assets in Lesotho (e.g., land).[26]

A consequence in Lesotho of economic deprivation and gender inequality is a high rate of transactional sex. Transactional sex, as distinct from prostitution, is characterized by sexual and romantic relationships, often involving love and companionship but also an intentional exchange of sex to procure money or material goods. Though these usually involve a regular partner for some period of time, there are a number of aspects of these relationships that result in high HIV risk:

multiple concurrent partnering, inter-generational relationships (normally older men with young women; sometimes older women with young men); highly unequal gendered power relationships resulting in unsafe sexual practices such as low condom use [27]. For young women, this is exacerbated by low hope and vision for an alternative future, as well as seeking to satisfy not only basic consumption needs but also social needs for goods that confer status (e.g. phone, nice clothes), influenced by global culture [28]. The latter is a particularly strong driver for young women who are not poor. HIV/AIDS affects women and men across the wealth/poverty spectrum, with different drivers.

Lack of economic opportunity in the rural areas also leads to high rates of internal and external migration. A recent study showed that female migration in Lesotho is primarily driven by economic "push" (rather than "pull") factors, often due to shocks to the household, such as job loss, death, or bad crops. Women's employment in sectors dominated by migrants is strongly correlated with HIV/AIDS: 55 percent of women working in garment factories and 38 percent of domestic workers are HIV positive, as opposed to the national average of 30 percent. [29] Migrants are far from home and their spouses, leading to multiple partnerships, in an environment not constrained by traditional and community norms and lacking social recreation.

For women this is exacerbated by unequal power relations, coerced sex, and low wages, where women factory workers often undertake sex work at night. Internal migration in Lesotho played a key role in increasing women and adolescent girls' vulnerability to HIV infection where poor rural women moving to urban areas were pushed them into accepting casual and concurrent, often unprotected, multiple sexual partners in exchange for food, housing, protection against violence or even for socializing. [30] These women often returned to rural homes where they also maintained a sexual relationship or were married, fueling HIV transmission. Migrant male mineworkers in southern Africa have been identified as the most affected population groups with regard to HIV and TB infection with living conditions that predispose them to HIV and TB. This situation for migrant mineworkers and their families is exacerbated by the migration patterns where migrants move between urban and rural areas and across and within country borders. While HIV testing and treatment services are often available at the mines for mineworkers, men do not access them for a variety of reasons.[31] For domestic workers and farmworkers, access to health services is even more difficult as these involve leaving the workplace and distance travel.

The second key driver of new infections is social and cultural norms. Many of these involve norms and practices related to gender roles, including expectations of what it means to be a woman and a man, and creating highly unequal power relationships that disfavor women. One particularly dangerous aspect of these norms is the acceptability and prevalence of gender-based violence (GBV), primarily intimate partner violence. GBV is strongly associated with gender discrimination, lower income and education levels, and adversely impacts health, productivity, and well-being of women and other vulnerable groups [32]. Over 85 percent of women in Lesotho report experiencing some form of violence in their lifetime, while 40 percent of men admit to having perpetrated violence against women. [33] GBV compounds HIV incidence and risk both directly, through physical trauma but also indirectly by increasing high-risk practices in both perpetrators and victims. [34] Those affected by GBV are not able to make and implement prevention decisions, such as negotiating safe sex with their partners or obtaining health services, due to low self-esteem, a controlling partner, and fear of personal violence. [35] In addition to causing physical harm and injury, GBV can result in physical illness, mental and social distress, depression, and suicide. In addition to norms related to GBV, other sociocultural norms related to masculinity present a number of additional drivers of risk. Sociocultural norms also drive HIV and AIDS through stigmatization. 2014 DHS data shows significantly reduced stigma between 2014 and 2009, but levels of stigma remain high. There were regional and differences in attitudes, and accepting attitudes generally increase with education and wealth quintile for both men and women. Stigma and discrimination can reduce willingness to be tested and treated. Depression and anxiety are linked to HIV infection, both as a complication and source of new infection: depression can lead individuals to engage risky sexual behavior, which can lead to exposure and further spread of the virus [36]; at the same time, a diagnosis of HIV/AIDS can trigger anxiety and depression [37], which can raise the possibility of risky behavior. Depression and anxiety can also lead to poor adherence to ART regimen.[38]

C.3 SCOPE OF WORK

This scope of work covers services that will be needed to support MCC in the Lesotho Compact Development. MCC is looking for a contractor that can clearly demonstrate experience in i) analyzing the multi-dimensional drivers of HIV, ii) developing appropriate responses, iii) strengthening health systems, and that can iv) provide evidence of the satisfactory completion of previous assignments to reduce the burden of HIV/AIDS within the past 12-15 years, preferably within Southern Africa. Previous successful experience should demonstrate ability to both design and implement programs that have reduced the burden of HIV/AIDS, citing project, regional or national level impact, result or outcome level indicators that positively changed during the length of activity and/or post activity.

This scope of work will require a contractor who is able to assemble a team of experts familiar with evidence-based interventions that have been proven to reduce the HIV/AIDS burden, and strengthened health systems. This team must include expertise in the social, cultural, economic, and governance drivers of HIV, and expertise in analyzing health systems failures, and an understanding of effective responses to all of these. The consultant will need to be able to assess and analyze: a) the Lesotho specific research, program evaluation and data, b) the international body of evidence related to HIV/AIDS reduction, with a strong emphasis on sub-Saharan Africa and southern Africa and c) the qualitative data collected by their own assessment in order to identify the factors preventing Lesotho from reducing the new incidence of HIV/AIDS infections and increasing the efficiency and effectiveness of its health systems.

The objectives of this award is to select a Contractor to provide MCC support in:

i) Assessing the multi-dimensional drivers of HIV and the challenges to effectively addressing the epidemic: social, cultural, economic, and governance, including political economy and health system drivers;

ii) Assessing opportunities to address these drivers through multi-dimensional programming, including supporting health systems reform and improving the public sectors ability to deliver effective preventative and curative care needed to sustainably reduce the social and economic burden of HIVAIDS;

iii) Assessing proposed opportunities to implement innovative financing, service delivery mechanisms which enable non-public investment in the sector and improve effectiveness of service delivery, including medical and behavioral approaches;

iv) reviewing, assessing, and providing feedback on the GoL's proposed concept notes and papers for reduction and prevention of HIVAIDS transmission, health service delivery and/or health system strengthening and

v) Identify and collect, as needed, data to inform the link between economic/income growth and improved health outcomes, and additional data/information needs for "deep dive" project design studies to be carried by the GoL.

Additional Option Years will be considered before the end of the Base Period, after which support is needed to review project design studies, collect data as needed, support investment memo development and entry into force planning.

vi) Support MCC to due diligence the implementation of the compact by the GoL; and

vii) Other duties as required.

Provided the contract is annually renewed past the base period, the Contractor will provide services to MCC over each phase of the MCC project cycle:

• Root Cause Analysis

• Concept and Project Proposals

• Economic Rates of Return and Beneficiary Analysis

• Due Diligence during Project Implementation

It is likely that the first two years contemplated for this contract will focus on Program Design with the last three years spent in providing due diligence services in support of MCC's oversight of the Project.

TABLE 1. MCC Project Cycle

MCC Project Phase Timing Contractor Services

Constraints Analysis / Root Cause Analysis

Base Period Literature Reviews related to the Lesotho health system, political economy of the health system, public financial management and inter-ministerial coordination as it related to HIV/AIDS, social, cultural, economic, poverty, and gender issues, programs, gaps, all potential drivers of HIV/AIDS, donor/implementer landscape; effective and ineffective interventions to address these issues.

Qualitative field assessments – physical, social conditions, practices, challenges, behaviors, administrative/management systems; focus groups, key informant interviews, etc.

Critically evaluate the root cause analysis of poor health related to HIV/AIDS provided by the GoL and intervention areas proposed to resolve problem.

Elaborate root- cause understanding and recommend, as needed, evidenced-based interventions to resolve identified problems.

Concept and Project Proposals

Base Period – Year 1

Support MCC to due diligence concept notes and project proposals proposed by the GoL; critically evaluate the program logics, including impact pathways, risks and assumptions.

Critically evaluate the relationships between program logics and project concepts and proposals.

Economic Rates of Return and Beneficiary Analysis

Year 1 – Year

Provide data and information needed by MCC for a cost-benefit and beneficiary analyses of proposed projects, critically analyze assumptions used to estimate an economic rate of return, and to estimate the distribution of benefits across poverty quartiles and gender.

Identify evidence that establishes the plausible links between proposed health, health systems or HIV/AIDS interventions on beneficiaries and economic/income impacts, as well as the distribution of those impacts by income and sex.

Project Design Year 1 – Year

Support to MCC to due diligence the implementation plans and proposals by the GoL (TORs for implementation contractors, Government Implementing Entity Agreements, Partnership Agreements, Social and Gender Integration Plan etc.; and contracts and contractor deliverables.)

Further develop initial project proposals through the development of specific objectives, associated activities required to overcome HIV/AIDS and health system constraints to development identified.

Due Diligence during Project Implementation

Year 2/3 through Year

Quality control in all aspects of selected programming.

Review of implementing contractor or partner work per MCC guidance

Targeted assessments and training that provide data for detailed project design

Review of evaluation proposals

Review of sustainability planning

In order for the Contractor to be able to rapidly and effectively mobilize to support MCC in evaluating initial Compact project proposals and alternatives and defining data/information needs, this scope outlines work and expertise that is expected to be needed during a Base Period of nine months, starting approximately in September 2018 and four additional one-year Option Periods. It is anticipated that as project development progresses into later phases, technical directives issued under this contract will be targeted to one or more sub-sectors, and the Contractor's team may evolve to include additional specialists who can review the GoL's project design.

C.4 TASKS

BASE PERIOD (TASKS 1 – 3)

Task 1: A) Assess the drivers and root causes of Lesotho's high HIV prevalence rate and new HIV infection rate, the efficacy of past and present projects in Lesotho and the region, and the donor landscape;B) Assess potential interventions and make recommendations;

Poor health related to HIV/AIDS is a cross-cutting problem, requiring a multi-sectoral response and systematic reviews have identified interventions for which there is compelling evidence of their impact on HIV/AIDS prevalence and incidence rates.

MCC's Root Cause Analysis to date has identified two main dimensions of the broader Poor Health related to HIV/AIDS constraint: 1) high rate of new infections; and 2) poor and inefficient service delivery. The Contractor shall work with MCC and the GoL to assess roots causes and potential interventions, and make recommendations. Sub tasks include:

Objective 1: Assess and prioritize the drivers of the high HIV infection rate in Lesotho

Assess the drivers of HIV/AIDS in Lesotho, analyze how those factors interact, and prioritize the most significant determinants of Lesotho's high HIV/AIDS prevalence and incidence rate. Among significant drivers, analyze differences by age, income, gender, location, employment sectors, or other relevant characteristics. Support this assessment with rigorous, evidence-based literature based on quantitative and qualitative data, with quantitative analysis of the best available data, and qualitative data collected in-country.

Key questions to be answered include:

a. What are the main drivers that have led to high prevalence and ongoing incidence rates in Lesotho? For example, what is the relative role of factors such as economic deprivation, lack of economic opportunities, migration, gender inequalities in power and opportunity, social norms for women and men, role of traditional systems, resources invested in prevention, approaches to prevention, political economy, general health service provision, poor coordination and financial management within the health sector? Other factors?

b. What are the sociocultural norms, practices and related factors that have contributed to the trends and current prevalence and incidence?

c. How are the drivers of HIV/AIDS different in Lesotho as compared to neighboring countries, and how have they prevented Lesotho from experiencing the same level of success as neighboring countries in reducing their HIV/AIDS prevalence and incidence rates? (E.g. Why is girls' retention in secondary school not a preventative factor as it is elsewhere in sub-Saharan Africa?)

d. What are the unique challenges and opportunities in the Lesotho context to effectively improve poor health related to HIV/AIDS: e.g. political economy, geography, climate, patterns of human settlement, culture, history, religion, gender and social dynamics, education, literacy, unemployment, poverty, social and welfare programs, donor histories and approaches, government financing, behavior change factors, etc.

Objective 2: Landscape Analysis - assess the strengths and weaknesses of the government, donors and NGOs in Lesotho to address poor health related to HIV/AIDS

a. Identify the GoL ministries and agencies that provide services that address the most significant drivers of and services responding to HIV/AIDS in Lesotho, and assess their strengths, weaknesses and coordination capacity.

Highlight services not provided by any ministry in Lesotho that are key to reducing HIV/AIDS in Lesotho. (Note:

At a minimum this includes the Ministry of Health, Ministry of Social Services, Ministry of Education, Ministry of Planning, Ministry of Finance, Ministry of Public Works and Ministry of Statistics.) Identify influential champions (either individuals or advocacy groups) that could play an important role in moving forward public policy.

b. Conduct a detailed assessment of the health system in Lesotho, with a focus on services related to HIV prevention and treatment, and the dimensions that help to explain inefficiencies and effectiveness/ineffectiveness of the system to address HIV/AIDs. This should include, but not be limited to, the following:

i. Issues related to health system governance, leadership and management.

ii. Main institutions and processes (at both national and sub-national levels) that are involved in health system planning and delivery, including government and…