ANNEX_ONE_final.docx

ANNEX ONE - Technical Directive #1 Determinants of Poor Health related to HIV/AIDS Assessment

Objective 1:

In two pages or less address each issue under Technical Directive #1, Objective 1, (a) and (b) below. The response to this objective should be included in the Contractor’s proposal, and will be used to evaluate the proposal. No further deliverables will be required related to this objective after contract signing, except as the issues are relevant to Objective 2 below.

Objective 1: Address the relationship, dynamics, challenges and opportunities of each issue as related to Lesotho high rate of new HIV infections:

a) Electronic medical records system

b) Male identity Note: The two issues presented above are not indicative of MCC priorities and are selected as illustrative examples to evaluate offeror skills and abilities only.

Objective 2:

Technical Directive #1, Objective 2, the response to this objective should be included in the Contractor’s proposal. The response will be used to evaluate the proposal and is the first technical directive that MCC anticipates issuing once a task order/contract has been signed. The proposed assessment plan shall demonstrate understanding of the requirement, problems to be resolved, feasibility of the proposed approach considering time and budget, and methods for controlling the quality of work. The strategy and methodology included in the proposal for the first technical directive shall include at a minimum:

a) mission objectives

b) methodology for accomplishing mission objectives

c) list of consultants contributing to mission objectives, their roles and estimated LOE

d) proposed mission schedule including lists of prospective people or groups to interview, locations to visit, and the research questions targeted for each person/group of individuals

e) timeline, including pre and post mission tasks such as desk review, analysis and presentation

Objective 2: 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.

Objective 2.1: Assess and prioritize the drivers of the high HIV infection rate in Lesotho

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.

Considering key questions listed above -- along with the global literature and knowledge base of evidenced-based measures to reduce new infections of HIV -- the Contractor shall propose a plan to assess the drivers of the high HIV infection rate in Lesotho. Drivers of new HIV infections shall be prioritized based on available evidence (quantitative or qualitative data) that indicates the level of significance a particular driver is having on the Lesotho epidemic.

Objective 2.2: 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 non-government actors, and their strengths and weaknesses.

iii. Health system engagement with the public, accountability mechanisms, and the strengths and weaknesses of the mechanisms.

iv. Supply chain for pharmaceuticals and supplies

v. Health information systems for population and patient monitoring, treatment, education, and supply chain. This should include an assessment of national, sub-national and facility-level collection of, reporting on, and analysis and use of health data, including incentives or disincentives as well as the availability and use of civil registration and vital statistics (CRVS) data.

vi. Infrastructure, including availability, accessibility, maintenance.

vii. Outreach programs to remote locations

viii. Private sector coordination for delivery of services

ix. Social and Behavioral Change Communications (SBCC).

For each of the considerations listed above, the contractor shall include analysis of effectiveness/ineffectiveness, challenges and opportunities. The contractor may choose to organize this assessment around the six WHO-defined building blocks of health system strengthening.

c. The GoL invests heavily in health services to prevent and respond to HIV/AIDS. Identify factors that motivate how the government spends resources on health and may influence the allocation of funds to improve health related to HIV/AIDS. Describe how the MoH plans, makes decisions, allocates funds, implements decisions, monitors, evaluates and sustains decisions taken/plans. Assess the MoH’s willingness and ability to allocate resources to the local level for planning and service delivery. (Note: It may be helpful to take the 2016 or 2017 MoH budget as an example and explain the processes used to develop and finalize the MoH budget and how successfully budget planning resulted in budget execution.) Explain processes used to prioritize health services and draft a budget responsive to priorities. Identify which departments develop and approve budget proposals in the MoH, and which offices in the government review and edit budget proposals from the MoH. Consider the following questions, as well: How did donor funds factor into the MoH budget planning? Once the MoH budget was approved, how was it communicated and distributed to districts? Does the private sector participate or have a role in the government planning process?

d. Describe and critically assess the roles and responsibilities of different government units (from the national to village level) including their fiscal (budget preparation, management and reporting) role and how the different units should relate to/coordinate with municipal or local leaders. Describe and critically assess operation and maintenance plans/frameworks that ensure sustainable supply of services.

e. The Lesotho MoH has been undergoing a process of decentralization, where certain responsibilities and budget are delegated to district health offices. Describe the progress to date and assess to what extent decentralization has occurred within the MoH and how it has affected service delivery, especially considering poorly served areas. Consider the following questions, as well: Is there a strong system of community-based volunteers linked to the MoH and/or other ministries? Are traditional healers, CBHWs, and/or midwives organized or linked with health posts or clinics, do they receive any type of incentive or salary? What are the strengths and weaknesses of decentralized authority in the health sector? Of the District Health Management Teams (DHMT)?,

f. Review the experience of the past decade in Lesotho with respect to prevention, including social and behavioral change communications (SBCC). What has been successful and unsuccessful? Why have donors and the government moved away from these approaches? What are the most promising new areas of this type of work, in Lesotho and elsewhere? What is the role of economic strengthening/livelihoods and social protection programs or components of SBCC programs? What impact have they had?

g. As a part of the GoL assessment, analyze past policy reforms that have had an impact – either negatively or positively. Consider if any additional reforms are necessary.

h. Describe and critically assess how the MoH or other government entities (e.g. Ministry of Planning or Ministry of Finance) coordinate various donor interventions. Describe the role of the National AIDS Council vs the Infectious Disease Department in the MoH, especially in regards to coordinating donor and government interventions specific to reducing HIV/AIDS. E.g. explore how a weak HIV/AIDS national coordinating mechanism and/or a strong network of Basotho HIV/AIDS focused NGOs has impacted the response.

i. Assess the strengths and weaknesses of all non-governmental key actors, including donors, and international and local NGOs, to address poor health related to HIV/AIDS (new infections and health service delivery).

j. How are different government and non-governmental programs, medical, behavioral, and economic, in Lesotho working to address the problem, and these drivers? What has been their impact? What factors have facilitated or hindered adoption of medical (e.g. VMMC, infant male circumcision, PREP) or behavioral practices (e.g. condom use, monogamy, delayed sexual debut) that are proven to prevent or reduce HIV/AIDS transmission? Where are the programming gaps and why have these gaps persisted?

k. Identify the main approaches to prevention and treatment, results (success and unsuccessful) and the reasons for these results. Identify similarities and differences between Lesotho and these other countries to assess relevance and likelihood of success. What have been the most successful interventions, and how do are the enabling conditions similar and different in Lesotho? Explain the main lessons learned, and state-of-the art responses.

i. Include in this review programs that have aimed at addressing differences by gender and age, eg. Programs targeting adolescent girls/young women (in and out of school); men and boys; migrant workers, rural vs. urban, high risk and hard to reach populations. Create a typology of different types of approaches targeting different populations, where they have been successful or not, and which ones have been or are ongoing in Lesotho.

ii. Review the design and data on the DREAMS program in Lesotho and other countries, including results to data on uptake and impact. While data on the other nine countries can be summarized at a higher level, provide as much detail as possible on the Lesotho experience to date. Include ‘DREAMS-like” programming implemented by other donors (e.g. Global Fund) and similar locally initiated programs (e.g. SLS, Her Chance, and others).

iii. Review programs in Lesotho that are not AIDS-specific but target the drivers of HIV identified above, e.g. Gender-based violence, social protection, sexual health education. Review successful programs addressing drivers in neighboring countries that have had an impact on HIV.

l. Assess and explain specific sub-national, village or community-level organizations, structures or cultures which may influence or take action on behavioral change, work to collectively address the disease burden, or otherwise affect the incidence and treatment of HIV/AIDS. In particular, assess power structures within communities and with external participants such as regional or national governments or NGOs.

m. Assess the capacity of national, local and community-based institutions to use data for analysis, reporting and decision making at national, subnational and community levels. This should include assessment of capacity of health-related infomediaries, which may analyze or pre-digest data for downstream use, and key influencers who interpret and publish information on health-related topics. Include in this assessment the extent to which data on social and gender-related health determinants (as well as medical and administrative data) are collected, analyzed and used in planning and decision-making to improve health services and outcomes.

Objective 2.3: Lesotho Health Systems Strengthening and Health Services related to HIV/AIDS Donor Landscape

Assemble a list and pertinent details of all the HSS and health services related to HIV/AIDS programs or projects, spanning the last decade. Programs or projects identified shall include donor, NGOs and government programs. Include programs that ended in 2011 or afterward, even if they started prior to 2008. Programs with annual budgets >$250,000 should be included. The list should be presented in table format and correspond to a geo-identified map and include, at a minimum, the following information: donor, implementing partner, geographic intervention area, start and end dates, length of activity, possibility for extension or follow-on program, budget/funding amount, conditions of funding if applicable (i.e. loan, grant, matching requirement, etc..), number of beneficiaries targeted, type of intervention and main objective and sustainability plan. The geo-identified map should indicate the location of the programs/projects listed in the table. Using existing data, work to rigorously assess what projects have operated where and what their impact has been on indicator on HIV prevalence or infection rates. Please give attention to interventions that have included innovative financing mechanisms (RBF, PPPs, etc.).

Objective 2.4: Assess potential intervention areas and recommended interventions

a. Assess what is unique about MCC’s role in the donor landscape and explore how MCC’s investment could be uniquely leveraged to reduce the burden of HIV/AIDS. Consider elements of MCC’s model, such as: condition precedents, implementation via the GoL, funds are granted and no repayment is required, 5 year compact program length with no extensions allowed, large investments (often >$30M per sector in compacts in country the size of Lesotho), MCC clearance on procurements, post-implementation impact evaluation, ability to leverage private-sector investment, past experience, etc.

b. Analyze the information gathered above and recommend promising interventions to significantly reduce HIV incidence and improve health system effectiveness that can be implemented within a five year timeline. The recommendations where possible should note other additional non health oriented interventions that may/can contribute to alleviate other factors driving the high HIV/AIDS prevalence and new infection rate. These recommendations should be evidence-based and provide a nomenclature through which MCC can determine the best interventions.

c. Identify potential opportunities for MCC to partner with other donors (e.g. PEPFAR, World Bank), in undertaking, adapting or scaling up interventions. Explain the advantages of these partnerships, over undertaking interventions unilaterally.

B. Deliverables and Due Dates:

1. Financial Plan and Draft Schedule/Timetable

a. Initial Budget proposal – considering deliverables requested, propose a budget including LOE for consultants, travel and any workshop, stakeholder meeting, communication or translation services required.

b. Draft Schedule and Timetable – propose a realistic schedule and timetable considering preparation, desk review, mission, reporting, reviews of submitted reports and presentations to MCC. Indicate when consultants will travel, be on mission and where they will be located when on mission (areas of Lesotho or the region they will visit and when). This timetable should indicate the time period required to undertake the above tasks from start to finish and should take into consideration that MCC will require at least five business days to review drafts or deliverable submissions.

Due Date: Due two weeks after the technical directive is issued, which MCC anticipates issuing immediately upon contract signing. (Note: Contractors should propose and identify consultants who are available to prepare and carryout this mission immediately after contract award.)

2. Assessment Mission Terms of Reference

a. Desk Review

· List of articles reviewed or people interviewed pre-mission

· Quantitative analysis of existing data and the impact of various projects

· Qualitative assessment of the Lesotho situation considering available literature and the experience the consultant team brings to the table (Note: Include references for all statistics or conclusion statements.)

b. Research Plan

· Research plan to be responsive to the technical directive objectives with clearly stated specific methods to be used

· Qualitative data synthesis and reporting plan that describes how the contractor will process and combine data collected, potentially from assessment teams traveling to different parts of the country in order to form conclusions.

· If consultant team proposed is not geographically co-located, explain how data analysis and reporting will be coordinated.

c. Logistics Plan

· Proposed Mission Schedule including travelers, Basotho consultants, travel dates, proposed meeting name and time and place. Mission can be divided into 2 or 3 teams visiting different locations or focusing on different themes. (This should be a more detailed version of the schedule/timetable proposed in Deliverable 1)

· Detailed budget proposal (This should be a more detailed version of the budget proposed in deliverable 1.)

d. Qualitative Assessment Tools

· Objectives and questions for Interviews/Focus Groups (need not be detailed).

· Qualitative assessment data analysis tools/methods the team plans to use (qualitative data analysis software should be used)

· Description of reporting tools, such as the software that will be used to create the geo-identified maps Due Date: Due three weeks after the technical directive is issued.

3. Assessment Mission

a. Carryout assessment mission Due Date: Within eight weeks of the technical directive being issued, the mission should be completed. (Note: It may be possible for consultant team members to carry out interviews pre or post mission depending on the location of both the consultants and individuals being interviewed.)

4. Post-Assessment Mission Report

a. Final Schedule, linked to meeting notes

b. Meeting notes shall include: dates, location, participants present, brief meeting notes Due Date: Due one week after return from mission.

5. Assessment Report and Presentation

a. Copy-edited written report that is responsive to the technical directive objectives.

b. Presentation to MCC and other relevant stakeholders of report findings and recommendations, which includes an annotated power point.

c. Recommendations for additional research, surveys and/or study.

Due Date: Assessment Report, presentation and recommendations for additional research, surveys and/or study due ten-fifteen business days after returning from Lesotho. Final draft or next version of the Assessment Report due within five business days after receiving comments from MCC.

C. Tentative Timetable:

Various factors may effect when the contract is signed, but the contractor should propose a team that can accomplish the objectives of the first deliverable per the estimated timetable below.

Mid to Late September – Contract signed

1. Financial Plan and Schedule/Timetable - due late September of early October, 2018

2. Assessment Mission Terms of Reference – due mid to late October, 2018

3. Assessment Mission – carried out in late October or early November, 2018

4. Post-Assessment Mission Report – due mid-November to early December, 2018

5. Assessment Report and Presentation - due mid to late December, 2018