ATTACHMENT 2_REVISED APS MCH, RI, N.pdf

ATTACHMENT 02 – REVISED APS 72065623APS00001/001

Amendment 01 issued: September 20, 2023

Second Round of Questions submitted: October 2, 2023 5:00 pm (Maputo time)

Closing Date and Time for Concept Papers: October 31, 2023, 11 am (Maputo time)

Subject: Annual Program Statement (APS) 72065623APS00001

Program Title: USAID Improved Maternal, Newborn, Child Health, Immunization and Nutrition Activity

Federal Assistance Listing Number: 98.001

Dear Prospective Applicants:

The United States Agency for International Development (USAID) Mission in Mozambique is seeking concept papers from qualified applicants for the USAID Improved Maternal, Newborn, Child Health, Immunization and Nutrition Activity. This Annual Program Statement (APS) publicizes the intention of the United States Government (USG), as represented by the United States Agency for International Development (USAID)/Mozambique, Integrated Health Office (IHO), to fund one or multiple awards to address the overarching APS program purpose. The purpose of this activity is to accelerate reductions in maternal, newborn, and child mortality and morbidity in high-burden regions of Mozambique by increasing the capacity of host country institutions, including local organizations, to improve access, quality, and sustained use of evidence-based maternal, newborn, and child health (MNCH) services, including routine immunization and nutrition services, as well as, promoting optimal MNCH, child development, and nutrition behaviors and practices.

This principal APS document outlines the goal, purpose, expected results, and priorities of the USAID/Mozambique Improved Maternal, Newborn, Child Health, Immunization and Nutrition Program and may result in none, one or multiple awards.

USAID is committed to engaging and working with local development partners to embrace their ideas on how to address sustainable development in Mozambique. Local partners are strongly encouraged to submit concept papers in response to one or more Results within this APS. Further guidance on how to apply as an individual organization or part of a consortium can be found in Section D.

The focus of this APS is to seek local and international development partners to proactively engage and, in some cases, collaborate and co-create to seize opportunities and solutions to implement the programmatic areas identified in the APS. Innovative ideas that seek to disrupt the status quo and

72065623APS00001

USAID Improved Maternal, Newborn, Child Health, Immunization and Nutrition Activity accelerate health gains are welcome. Prospective local and international Applicants will be provided a fair opportunity to develop and submit a competitive concept paper to USAID for potential funding by the closing dates indicated in the APS.

Prospective Applicants will be provided a fair opportunity to develop and submit competitive concept papers to USAID/Mozambique for potential funding under this APS. The issuance of this APS calls for Applicants to first submit a short concept paper that will be reviewed for responsiveness to the overall purpose and all or a selection of the Results, and then scored according to the evaluation criteria. If an Applicant is successful in the concept paper stage, Applicant representatives may be invited to join a co-creation workshop. Following the co-creation process, selected Applicants (individual organizations and/or consortia developed at concept paper stage or during co-creation) may be requested to submit a full application, the content and format of which will be provided in greater detail by the Agreement Officer (See more details in “merit criteria” section) . USAID reserves the right to fund any or none of the concept papers or applications submitted in response to this APS. Issuance of this APS does not constitute an award commitment on the part of USAID, nor does it commit USAID to pay for any costs incurred in preparation or submission of the concept paper, comments/suggestions, or the application.

USAID also reserves the right to not conduct a co-creation workshop and request full applications from successful Applicants at concept paper stage.

The APS and any future amendments (posting questions and answers from interested parties or any other changes to the overall APS document), as well as any future addenda to this APS will be posted on www.grants.gov . It is the responsibility of the applicant to download the full APS document through the web page mentioned above. USAID bears no responsibility for data errors resulting from transmission or conversion processes. Please send any questions to the points of contact listed in Section D. The deadline for questions is shown above. Responses to questions received prior to the deadline will be furnished to all potential applicants through an amendment to this notice posted to www.grants.gov.

USAID/Mozambique will hold a pre-application conference on the date shown above. Should you intend to participate in the aforementioned conference, please provide the names and email address of the individuals that will represent your organization to the points of contact identified in Section D, no later than August 22, 2023, at 04 pm (Maputo time).

Issuance of this notice does not constitute a binding commitment on the part of the U.S. Government, nor does it commit the U.S Government to pay for costs incurred in the preparation and submission of any concept papers, engagement, collaboration, co-creation, or full applications. USAID reserves the right to fund any or none of the applications submitted under this APS.

Thank you for your interest in USAID programs.

Sincerely, Patrice Lopez Agreement Officer Office of Acquisition & Assistance http://www.grants.gov/ http://www.grants.gov/

TABLE OF CONTENTS

ACRONYM TABLE 2

SECTION A: PROGRAM DESCRIPTION 4

Statement of Purpose 4 A.1 Background 4

Technical Analyses 5 A.2 Statement of APS Goal, Purpose, and Expected Results 10 A.3 Geographic Focus 15 A.4 Cross-cutting Programmatic Principles and Approaches 16

Gender 16 Localization 18 Disabilities 19 Conflict and Instability 19 Sustainability 20 Environmental Compliance Considerations 21 Host Government, Donor, and other Counterpart Collaboration 22

A.5 Monitoring, Evaluation and Learning (MEL) 23 A.6 USG Strategic Priorities and Alignment 24 A.8 Legislation 26

SECTION B: FEDERAL AWARD INFORMATION 27

B.1 Estimate of Funds Available 27 B.2 Start Date and Period of Performance 27 B.3 Expected Number of Awards 27 B.4 Expected Implementation Mechanism 28 B.5 USAID’s Substantial Involvement 28 B.6 Intellectual Property 30 B.7 Environmental Impact 30 B.8 Authorized Geographic Code 31 B.9 Benefiting Geographic Areas 30

SECTION C. ELIGIBILITY INFORMATION 32

C.1 Eligibility Criteria 32 C.2 Cost Share 32

SECTION D. APPLICATION AND SUBMISSION INFORMATION 34

Annex I – Concept Paper Format……………………………………………………………………………………………………………42 Annex II – Budget Template ………………………………………………………………………………………………………………….45

Appendices:

ACRONYM TABLE

ADS - Automated Directives System AO - Agreement Officer AOR - Agreement Officer’s Representative APS - Annual Program Statement BEO - Bureau Environmental Officer CA Cooperative Agreement CFR - Code of Federal Regulations DUNS - Data Universal Numbering System EA - Environmental Assessment ECD - Early Childhood Development FP - Family Planning GH - Global Health Bureau GNI - Gross National Income HIV - Human Immunodeficiency Virus HTSP - Healthy Timing and Spacing of Pregnancy IEE - Initial Environmental Evaluation IR - Intermediate Result IYCF - Infant and Young Child Feeding LARC - Long-Acting Reversible Contraceptives LMIC - Low- and Middle- Income Countries MDGs - Millennium Development Goals MEL - Monitoring, Evaluation, and Learning MNCH - Maternal, Newborn, and Child Health MNCHI - Maternal, Newborn, and Child Health and Immunization MNCHI+N - Maternal, Newborn, Child Health, Immunization, and Nutrition MOV - Missed Opportunities for Vaccines MRC - Merit Review Committee NGOs - Non-Governmental Organizations PEPFAR - President’s Emergency Plan for AIDS Relief RCE - Request for Categorical Exclusion RH - Reproductive Health RI - Routine Immunization SBC - Social and Behavior Change SAM - System for Award Management, Registration, Renewal, & Migration SDGs - Sustainable Development Goals STA - Supportive Technical Assistance UEI - Unique Entity Identifier USAID - United States Agency for International Development USG - United States Government WASH - Water, Sanitation, and Hygiene WHO - World Health Organization

USAID IMPROVED MATERNAL, NEWBORN, CHILD HEALTH, IMMUNIZATION AND NUTRITION ACTIVITY1

SECTION A: PROGRAM DESCRIPTION

Statement of Purpose

The U.S. Agency for International Development (USAID) Mission to Mozambique is pleased to announce the USAID Improved Maternal, Newborn, Child Health, Immunization and Nutrition (MNCHI+N) Annual Program Statement (APS). MNCHI+N seeks not only to accelerate reductions in preventable maternal, newborn, and child morbidity and mortality in geographic focus areas of Mozambique, but to improve the health and nutritional status of women, children under five, and youth. The proposed Activity will take advantage of opportunities in the health sector to enhance the Mission’s relationship with the government of Mozambique (GRM) as well as engage with the private sector and civil society for improved MNCHI+N. In alignment with USAID’s ambitious Localization Agenda, this Activity will prioritize leadership and capacity strengthening across the GRM and local organizations to achieve and consolidate quality MNCHI+N promotion of healthy behaviors and service provision at facility and community levels. The MNCHI+N Activity builds on Mozambique’s health and development progress to date through diversified capacity and system strengthening to ensure quality, integrated, and comprehensive MNCHI+N throughout the continuum of care. USAID will build on previous projects high impact practices and evidence-based interventions to ensure elevated and sustained quality service provision in northern and/or central Mozambican provinces with consistently poor health indicators. Moreover, through the potential of this APS process, USAID seeks partners with which to co-create novel and innovative ideas for accelerated and sustained MNCHI+N gains.

1 For the purpose of this APS, USAID refers to this prospective Activity as “Improved Maternal, Newborn, Child Health, Immunization, and Nutrition” (MNCHI+N). Applicants are encouraged to propose a new project name aligned with their proposal.

A.1 Background

Mozambique is a low income, sparsely populated country with high fertility and mortality rates,2 that ranks 185 out of 189 countries in the 2022 UNDP Human Development Index, dropping four places since

2020.3 Mozambique’s high poverty rate (63 percent live on less than $2 a day)4 is perpetuated by frequent natural disasters, a high disease burden, high population growth, low agricultural productivity, insecurity in the northern region, and a highly unequal distribution of wealth. The northern and central regions combined account for 79% of the population and experience severe resource limitations. Both have multidimensional poverty indices that are twice as large as that of the southern region3.

Mozambique has an extremely young and predominantly rural population, approximately 45 percent of the population is younger than 15 years of age and 68 percent live in rural areas. Primary school completion rates remain low at 52 percent (55 percent for males, 49 percent for females), with 39.9 percent overall illiteracy rate (51% are female and 27.4% male.)5 6

Technical Analyses

Maternal Health: According to the most recent Demographic and Health Survey (DHS) from 2011,7 the maternal mortality ratio remains extremely high at 408 deaths per 100,000 births, and the lifetime risk of maternal death for women in Mozambique is high (1:67 women die in childbirth) in comparison to the global average of 1:92.8 Low quality of care continues to hinder progress in addressing drivers of maternal mortality, including hemorrhage (25 percent), ruptured uterus/obstructed labor (19 percent), postpartum/post-abortion sepsis (15 percent), eclampsia (13 percent), HIV (13 percent), and malaria (10 percent).9 Forty percent of maternal deaths in Mozambique occurred due to delays in reaching health facilities to receive emergency obstetric care, 14 percent experienced delays receiving care once reaching the health facility, and 15 percent experienced both delays.10 According to Mozambique’s Countrywide Mortality Surveillance for Action (COMSA) from 2019-2020, 47 percent of maternal deaths take place in the community. While Mozambique observed some improvements in skilled birth attendance and number of antenatal care (ANC) visits per the IMASIDA 2015 report, COVID-19 dramatically impacted service delivery in Mozambique; cesarean sections dropped 28 percent, first ANC visits within the first trimester dropped 26 percent, hospital deliveries dropped 4 percent, home deliveries rose 74 percent.11 Recent results from DHS 2022 show that hospital deliveries are at 65% and 87% of pregnant women attend an ANC with a skilled professional.12 A high adolescent pregnancy rate

2 2017 Population CENSUS - Fertility Rate 5.2; Infant Mortality Rate 67.3; Maternal Mortality Rate 451.6 3 UNDP Human Development Index https://hdr.undp.org/data-center/country-insights#/ranks 4 Mozambique Multidimensional Poverty Analysis Status and Trends (January 2019), Embassy of Sweden at 4.

Alkire, S., Kanagaratnam, U., and Suppa, N. (2022). The global Multidimensional Poverty Index (MPI) 2022 disaggregation results and methodological note. OPHI MPI Methodological Note 53, Oxford Poverty and Human Development Initiative, University of Oxford.

5 Instituto Nacional de Estatistica-Mocambique 2019/20 Household Budget Survey (HBS) 6 UNESCO Institute for Statistics (2018).

7 This is the most recent DHS data available. The next DHS survey was initiated in 2022.

8 https://data.worldbank.org/indicator/SH.MMR.RISK?locations=MZ 9 Chavane, L.A., Bailey, P., Loquiha, O. et al. Maternal death and delays in accessing emergency obstetric care in Mozambique.

BMC Pregnancy Childbirth 18, 71 (2018). https://doi.org/10.1186/s12884-018-1699-z 10ibid 11 das Neves Martins Pires, P.H., Macaringue, C., Abdirazak, A. et al. Covid-19 pandemic impact on maternal and child health services access in Nampula, Mozambique: a mixed methods research. BMC Health Serv Res 21, 860 (2021).

https://doi.org/10.1186/s12913-021-06878-3 12 Instituto Nacional de Estatística (INE) e ICF. 2023. Inquérito Demográfico e de Saúde em Moçambique 2022–23. Maputo, Moçambique e Rockville, Maryland, EUA: INE e ICF.

https://hdr.undp.org/data-center/country-insights#/ranks

(180 births per 1000 women among girls aged 15 to 19)13 also has implications for service provision: this is a group with high risk of obstetric complications, low antenatal care attendance and who may be subject to disrespectful intrapartum care.14

Family Planning: While modern contraceptive prevalence (mCPR) is reported to have risen from 11 percent in 2011 (DHS 2011) to 25 percent in 2022 (DHS, 2022), the fertility rate still is among the 10 highest in sub-Saharan Africa15 of 4.9 children per woman. Additionally, there are high rates of teenage pregnancy, particularly in the northern regions according to the DHS (2022). For adolescents between the ages of 15 to 19, 42 and 31 percent reported having had a child or were pregnant at the time of the survey in Nampula and Zambezia, respectively. In Niassa and Tete, the percentage of teenage pregnancies is 52.3 and 39.7, respectively.16 These data highlight a large, and growing number of women and adolescents who could benefit from a comprehensive, quality health promotion and service provision of reproductive health and family planning (FP) services as part of MNCHI+N, including offer of voluntary post-partum FP and reproductive health services that are youth-centered and/or tailored to being a first-time parent.

Newborn and Child Health: In 2022, the demographic and health survey reported a newborn mortality rate of 24 per 1,000 live births, an infant mortality rate of 39 per 1,000 live births, and an under-five mortality rate of 601 per 1,000 live births in Mozambique. The majority of newborn deaths occur in the first six days of life, due to prematurity (43 percent), asphyxia (27 percent), and sepsis (13 percent).

Despite increases in coverage of key MNCH interventions, newborn mortality has not decreased as expected.17 Mozambique is among the 54 countries off-track to meet the under 5 mortality target of less than 25/1000 live births, with post-newborn mortality contributing almost 60 percent of all under-five mortality.18 Amongst children, malaria, pneumonia and diarrhea remain the leading, preventable causes of death, and only 56.5 percent of children with pneumonia receive treatment, and 61.5 percent and 21 percent with diarrhea are treated with oral rehydration solutions (ORS) or recommended home fluids (RHF) and ORS+Zinc, respectively.19 These data similarly highlight challenges in requesting, accessing and receiving timely, quality care whether at the community or facility level.

Routine Immunization: The estimated number of children that have not received a single shot of a routine vaccine (i.e. zero dose children) in Mozambique increased from 7 percent in 2019 to 32 percent in 2022, placing Mozambique among one of the highest zero dose countries worldwide and one at risk for outbreaks of diseases that are on the verge of eradication, such as polio20. Vaccine coverage in Mozambique has stagnated, and in some areas declined, due to a number of factors including COVID- 19’s disruption to health care seeking behaviors, limited awareness of immunization benefits and/or ability to access immunization services, political instability, natural disasters such as cyclones, 13 UNFPA: Disturbing rise in teenage pregnancy, child marriage, gender-based violence and HIV infection in adolescent girls in East and Southern Africa – we need to act collectively and with urgency, 2022:

https://mozambique.unfpa.org/en/news/disturbing-rise-teenage-pregnancy-child-marriage-gender-based-violence%C2%A0-and-hiv-infection#:~:text=Countries%20in%20the%20East%20and,per%201000%20births%20to%20women.

14WHO Evidence Brief, 2019: Adolescent Pregnancy: https://www.who.int/publications/i/item/WHO-RHR-19.15

15 IMASIDA 2015

16 DHS, 2022

17 Getting to 2030: Maternal and Child Health and Nutrition Technical Roadmap https://www.usaid.gov/sites/default/files/documents/USAID_MCHN_RoadMap_single_Final_508.pdf 18 ibid

19 IMASIDA 2015

20 Recovery Plan for Mozambique Immunization Services: Leveraging COVID-19 to Make a More Resilient Program https://mozambique.unfpa.org/en/news/disturbing-rise-teenage-pregnancy-child-marriage-gender-based-violence%C2%A0-and-hiv-infection#:%7E:text=Countries%20in%20the%20East%20and,per%201000%20births%20to%20women https://mozambique.unfpa.org/en/news/disturbing-rise-teenage-pregnancy-child-marriage-gender-based-violence%C2%A0-and-hiv-infection#:%7E:text=Countries%20in%20the%20East%20and,per%201000%20births%20to%20women https://www.who.int/publications/i/item/WHO-RHR-19.15 https://www.usaid.gov/sites/default/files/documents/USAID_MCHN_RoadMap_single_Final_508.pdf insufficient vaccine supply and other health system challenges. This stagnation is most stark in northern Mozambique, particularly Nampula and Zambezia with 300,774 and 115,022 zero dose children respectively. The neighboring provinces of Niassa and Tete also have large zero dose populations (53,027 and 21,354). Completion of the Pentavalent vaccine, or Penta, which is given in 3 doses from ages 2- 4 months and protects against five major infections including diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type b, is often used as a proxy indicator for the strength of a routine immunization system. In a recent analysis of National Immunization Coverage, WHO/UNICEF estimated that from 2019-2021, during the peak years of COVID-19, the number of children receiving all 3 Penta doses decreased by 31 percent, and the number receiving just one dose decreased by 24 percent. Prior to COVID-19, the percentage of children immunized against major vaccine-preventable diseases increased only marginally from 63 percent in 200321 to 66 percent in 201522. In summary, despite vaccinations being one of the most cost-effective and impactful interventions, the immunization delivery and uptake in Mozambique had only slowly improved before COVID-19, and now those small gains are reversing or stagnating.

Nutrition: Mozambique has a high prevalence of malnutrition in children under age five (CU5) with 38 percent stunted23 and 4.4 percent wasted,24 high levels of micronutrient deficiencies (anemia affects 73 percent of CU525 and 54 percent of women of reproductive age26), and poor infant and young child feeding (IYCF) practices. Nationally, wasting rates have stagnated over the last few years; however, due to seasonal shocks and stress factors (including natural disasters and regional conflict), there is a high prevalence of localized wasting in the northern provinces of the country, where 9.1 percent of CU5 in Nampula are wasted.27 The underlying causes of undernutrition are complex and include poor dietary diversity and inadequate infant, young child, and maternal feeding practices. For example, nationally, 41 percent of infants less than 6 months old are exclusively breastfed and only 30 percent of children aged 6 months to 23 months reach a minimum diet diversity.28 Cereals and starchy roots provide 80 percent of energy supply and the consumption of micronutrient rich foods is poor.29 A Cost of the Diet Study projects the majority of Mozambican families can only afford an energy-only diet.30 According to the 2011 DHS 54% of mothers between the ages of 15-19 years are anemic and 15% are classified as thin.

The age of childbearing is young in Mozambique and in 2015, 46% of girls between the ages of 15-19 started having children. Relative to older mothers, adolescent girls are more likely to be malnourished and have a low-birth-weight baby who is more likely to become malnourished, and be at increased risk of illness and death, than those born to older mothers. For example, the 2011 DHS found an infant mortality rate of 100 per 1000 live births among mothers under age 20, compared to 67 per 1000 live

21 DHS 2003

22 IMASIDA 2015

23 UNICEF Data Set Stunting (Survey Estimates, National and Disaggregated) https://data.unicef.org/resources/dataset/malnutrition-data/ 24 UNICEF Data Set Wasting (Survey Estimates, National and Disaggregated) https://data.unicef.org/resources/dataset/malnutrition-data/ 25 WHO Data Set Prevalence of anemia in children aged 6-59 months https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-anaemia-in-children-under-5-years-(-) 26 WHO Data Set Prevalence of Anemia in pregnant women aged 15-49 https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-anaemia-in-pregnant-women-(-) 27 Instituto Nacional de Estatistica-Mocambique 2019/20 Household Budget Survey (HBS) 28 Ministerio de Agricultura. Relatório do Estudo de Base de Segurança Alimentar e Nutricional de 2013 29 Fill the Nutrient Gap- Nutrition Situation Analysis Framework https://drive.google.com/file/d/1iQ_Pqfpcg6Cc5Rf00ajnGoKDT9MdRwpw/view 30 Fill the Nutrient Gap- Nutrition Situation Analysis Framework https://drive.google.com/file/d/1iQ_Pqfpcg6Cc5Rf00ajnGoKDT9MdRwpw/view https://data.unicef.org/resources/dataset/malnutrition-data/ https://data.unicef.org/resources/dataset/malnutrition-data/ https://data.unicef.org/resources/dataset/malnutrition-data/ https://data.unicef.org/resources/dataset/malnutrition-data/ https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-anaemia-in-children-under-5-years-(-) https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-anaemia-in-children-under-5-years-(-) https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-anaemia-in-pregnant-women-(-) https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-anaemia-in-pregnant-women-(-) https://drive.google.com/file/d/1iQ_Pqfpcg6Cc5Rf00ajnGoKDT9MdRwpw/view https://drive.google.com/file/d/1iQ_Pqfpcg6Cc5Rf00ajnGoKDT9MdRwpw/view births among mothers between the ages of 20-29 years.31 In addition, there are inadequate sanitation resources, and access to potable water is limited, with 28.7 percent of families using unprotected water sources and 14.1 percent using surface water.

Early Childhood Development There is no population-level data on children’s early childhood development (ECD) outcomes in Mozambique. However, it is estimated that 61% of children are at risk of poor development.32 According to the 2011 DHS, around 96% of preschool children, especially in rural areas, do not benefit from education and care from a specialized institution; the majority of children grow up mostly cared for by older children while parents are engaged in work. According to the Strategy document of the Integrated Development of the Preschool Child (DICIPE, 2012), there were about 4.5 million children under the age of 5 (CU5) in the country, of which only 66,000 (4%) had access to preschool education institutions, mostly managed and promoted by civil society entities and the private sector in urban settings. In a 2022 study by Advancing Nutrition in Nampula, only 4% of parents reported engaging their children (aged 0-23 months) in 4 or more activities in the last 3 days to support learning and 76% of children in the study were at risk of developmental delays.33 ECD integrates responsive care and early learning with nutrition services and health services, promoting optimal growth and development outcomes for children as part of the Nurturing Care Framework. ECD is only at an initial phase of wide dissemination in Mozambique, with established networks that advocate public and private sectors to embrace ECD in their activities and policies.

Health System: Systematic issues like resource allocation, shortages of staff, stockouts of essential commodities, unequal deployment of staff, inadequate infrastructure, and variable availability of services between different geographic areas (e.g. northern provinces versus southern provinces; urban versus rural populations), and between the poor and the non-poor exacerbate gaps in access and quality provision of care. Patients routinely experience long waiting times and poor service (a recent study revealed that the average patient/provider consultations take less than 5 minutes). Rollout of nationally approved guidelines remains a challenge due to low staff bandwidth and awareness. Particularly concerning are patient reports of poor communication and treatment by health care providers, with 55% noting fear of mistreatment by providers as a key barrier to accessing family planning in a recent study by USAID/Mozambique’s Improve Family Planning Initiative (IFPI). These multifaceted challenges demonstrate significant need for interventions that address systemic issues.

Staffing issues exist at the community and facility levels. Beyond the chronic shortage of healthcare providers, there is a lack of representation of native local language speakers among facility staff (only about 50% of the population speaks Portuguese34) and health care providers and workers are often not representative of their catchment areas. Many Mozambicans' first link with the healthcare system is through the APE (Agente Polivalente Elementar) or other community health actors from their community. Data from 2020 indicates a gap in labor force gender balance of these workers, where 26.3% were women and 75.8% were men. The gender imbalance may affect access to information

31 DHS 2011

32 Lu et al. 2016.

33https://www.advancingnutrition.org/resources/integrating-responsive-care-and-early-learning-nutrition-delivery-improve-early-childhood 34 Mozambique Ministry of State Administration, 2014 District Profiles around SRH and maternal and child health as women may not be comfortable discussing such issues with a male APE.35

Another study published in 2021 looking at missed opportunities for vaccines (MOV), which the WHO defines as “any contact with health services by an individual who is eligible for vaccination, which does not result in them receiving all the vaccine doses for which he or she is eligible,” found that rates of MOVs were higher in Mozambique than in many other countries assessed. Overall, of the children eligible and due for vaccinations at the start of a health facility visit during the study, 76 percent had a MOV.36 This was mainly due to outdated or lack of information among caregivers and providers about what vaccines were needed when, poor facility practices, lack of curative and preventive service integration, inadequate tracking systems for vaccination records, and in some cases, limited supply.

Limited supply or challenges with commodity acquisition is a significant issue in Mozambique. While there are a number of investments addressing supply chain issues (USAID/Mozambique’s AMOSTRA, CHEGAR, and PSM) and this lies firmly outside of the scope of this Activity, improvements in facility-level management of commodities and other resources will be an essential component to improve access, delivery and experience of MNCHI+N care among clients.

Finally, Mozambique has struggled to collect and manage key MNCHI+N data to inform timely decision-making. In recent years, there have been investments to consolidate data management systems and to formalize Data Quality Improvement (DQI) processes to improve ownership at the facility and district level. However, gaps remain in terms of available technology, human resources and skills to collect data in digital platforms routinely. A study of Health Information System Data from 2009 to 2012 found that facility-based data audits, targeted training and supervision, equipment purchase/ maintenance, and data audit and feedback meetings are associated with significant increases in public-sector HIS data concordance37. In order to make decisions based on the most up-to-date information, there needs to be greater capacity to collect, store, analyze, interpret, and use health data for improved decision-making.

Lessons learned: The USAID flagship bilateral MNCH project (2019-2024), Alcancar was the subject of an external mid-term evaluation which identified successes and important recommendations for future USAID support. The evaluation (https://pdf.usaid.gov/pdf_docs/PA00ZG79.pdf )focused on seven innovations implemented by the Alcancar project and identified ways to improve the quality of services and care provided to women and children. Per the evaluation, obstetric simulation practice sessions and health care improvement collaboratives implemented at health facilities improved accountability amongst providers who were trained to address specific scenarios and contributed to a changed culture within health facilities. A restructured Supportive Technical Assistance (STA) component, capable of withstanding future shocks due to natural disaster, pandemic or other emergency, should focus on creating a continuing learning structure and support the development of a library of videos and manuals related to clinical practices, treatments, and outcomes at the district and facility level. Highlighted focus areas for future technical assistance at the provider and system level include improved quality of

35 Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique’s community health workforce Rosalind Steege, Miriam Taegtmeyer, Sozinho Ndima, Celso Give, Mohsin Sidat, Clara Ferrão & Sally Theobald (2020)

36 Magadzire BP, Joao G, Bechtel R, Matsinhe G, Nic Lochlainn L, Ogbuanu IU. Reducing missed opportunities for vaccination in Mozambique: findings from a cross-sectional assessment conducted in 2017. BMJ Open. 2021 Dec 30;11(12):e047297. doi: 10.1136/bmjopen-2020-047297. PMCID: PMC8718423 37 Effects of a health information system data quality intervention on concordance in Mozambique: time-series analyses from 2009–2012. Wagenaar, et al. Popul Health Metr. 2015; 13: 9. Published online 2015 Mar 26.

about:blank https://pdf.usaid.gov/pdf_docs/PA00ZG79.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4377037/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4377037/ prenatal consultation, identification of risk factors, counseling, documentation of patient history, postpartum hemorrhage management, and respectful care.

Evidence from the USAID/Mozambique flagship project for nutrition, Transform Nutrition, as well as centrally-managed USAID Advancing Nutrition, demonstrated the importance of addressing the underlying factors of malnutrition and improving coordination with stakeholders and complementary programs. From the Transform Nutrition mid-term evaluation (not publicly available), central observations of the project were the need for improved engagement with community leaders as this encourages participation of all community members, particularly target groups (mothers, women of reproductive age, and children) in program activities and sustained behavior change. Ensuring solutions are locally-led and leveraging locally available resources improves adoption and sustainability of interventions and behaviors.

Previous MNCH investments, such as USAID’s Maternal and Child Health Integrated Program (MCHIP), Maternal and Child Survival Program (MCSP) and Alcancar, have found that routine immunization has a tendency to become a neglected, under-resourced area with corresponding poorer results in comparison to other technical areas within larger integrated projects. In 2021, as a response to this challenge, USAID bought into the field support mechanism MOMENTUM Routine Immunization Transformation and Equity (M-RITE) to provide leadership in strategic planning, coordination, micro-planning, and operationalization of vaccination service delivery for both RI and COVID-19. In addition, there are several studies currently underway looking at how the country was able to effectively roll-out the COVID-19 vaccine as well as challenges and progress in terms of RI and COVID-19 integration.

Findings, lessons learned, and best practices identified from these studies, once they are publicly available, should be incorporated into the activity design.

A.2 Statement of APS Goal, Purpose, and Expected Results This new MNCHI+N design will continue support for the GRM and will build on lessons learned from current and previous projects and activities; while also seeking innovations and novel approaches to realizing the results of improved MNCHI+N. This includes key lessons from USAID ALCANCAR, USAID’s Maternal and Child Health Integrated Program (MCHIP), Maternal and Child Survival Program (MCSP), M-RITE, Transform Nutrition, and USAID Advancing Nutrition, as detailed above. USAID evaluated these lessons learned, and though USAID recognizes that while standalone activities (e.g. for immunization) were successful, there is a strong desire to ensure MNCHI+N services are integrated to address patients’ health issues holistically and ensure MOVs are minimized. Integrated service provision also improves the patients’ experience of care and creates efficiencies for health care workers. This APS includes an integrated set of activities to comprehensively support the adoption of healthy behaviors and norms and promote quality service delivery, but USAID/Mozambique expects dedicated focus to each element

- immunization, maternal, newborn, child health and nutrition. Moreover, this Activity will include the ability to provide surge support through emergency funding for immunization campaigns related to outbreaks.

Furthermore, the proposed Activity will take advantage of opportunities in the health sector to enhance the Mission’s relationship with the GRM as well as engage with the private sector and civil society for improved MNCHI+N. Moreover, the Activity will build on previous health investments of high impact practices and evidence-based interventions and will leverage USAID’s investments beyond the health sector to support multi-sectoral innovations and efficiency. The Activity will coordinate and partner with other USAID-funded, and aligned donor activities, being implemented in the same geographic area to leverage and complement U.S. government and other donor investments.

APS Purpose: The Improved MNCHI+N award(s) will contribute to the results identified below. Each result represents the intended improvements over the next five years. These results are intended to improve the utilization of health services. USAID recognizes that there are challenges, needs, and gaps which may undermine these result areas, and therefore request Applicants to work with USAID and other key stakeholders in the co-creation process to validate and iterate what is needed for these Results to be achieved. Co-creation enables coordinated problem-solving and solution development, making it easier to identify opportunities for innovation and systems changes. Co-creation further offers a valuable platform for amplification of local voices and opportunities and for local stakeholders to forge new network connections and partnerships through which to implement activities (note: not all concept paper submissions will pass the first review and therefore, not all submission will be invited to attend the co-creation process) APS Goal: Improve maternal, newborn, and child health, -including increased routine immunization and reduced malnutrition - to decrease deaths from preventable causes and help women, newborns and children thrive in central and northern Mozambique (Nampula, Zambezia, Niassa and/or Tete - noting that additional/alternative geographies may be explored throughout the life of the Activity, and that targeted central level support to benefit the entire country is envisioned).

Expected Results

APS Theory of Change: IF there is increased adoption of healthy behaviors, improved access to health services, improved provision of quality services, and strengthened health systems, leading to improved utilization of health services THEN there will be improved MNCHI+N outcomes in select central and northern Mozambican provinces that will result in reduced mortality and morbidity and a pathway for families to thrive.

Intermediate Result (IR) 1: Increased adoption of healthy MNCH, immunization and nutrition behaviors - Identifying and addressing underlying factors and barriers to positive health behaviors and encouraging adoption of positive behaviors through proven social and behavior change interventions is key to improving individual and community health. This includes working with communities to understand root causes of certain behaviors and practices, including social and cultural norms, underlying factors (like resource availability, desirability, accessibility) and establishing trust to collaboratively find solutions that are contextually appropriate and accessible, including leveraging innovative or supportive technologies where feasible (such as social media platforms). This Activity should explicitly target adolescents, women, parents, guardians, and other caregivers of CU5 as well as community leaders and other influencers.

The role of community health workers will also be vital to these efforts, and therefore, ensuring that they have the most up-to-date information and enhanced skills for counseling and engaging with the community via multiple entry points will be a key component of this Activity. Through these means, this Activity should seek to improve care-seeking and routine household behaviors, including nutrition and child feeding behaviors, and strengthen the capacity of individuals and communities to manage their own health and identify danger signs and symptoms of concern for pregnant women and adolescents, newborns, and children.

At the heart of this Activity is a respectful approach to analyzing and influencing social and gender norms to improve MNCHI+N in the targeted communities. Formative research and evidence from previous projects will guide the approach to this Activity. Community health workers, community leaders, and other key influencers will play a critical role in facilitating normative change to ensure acceptability and appropriateness of approaches. Engagement with vulnerable groups like pregnant and lactating women, adolescents, and people with disabilities will help identify and address barriers and drive engagement with these target groups. Empowering and supporting caregivers to provide nurturing care to support healthy early childhood development and optimal growth should be included as it improves nutrition and health outcomes for children 0-23 months. Activities should focus on understanding and addressing decision-making power and agency, especially with respect to women, girls, and youth, enhancing access to information and resources to adopt health behaviors, and the creation of locally developed solutions to overcome barriers to successful adoption of behavior change.

Platforms, such as steering committees, should be utilized to encourage participation from a variety of actors, particularly those from marginalized groups, and ensure accountability. Implementing Partners will be expected to conduct further gender and social inclusion analysis and create responsive action plans to address barriers to access.

As there is a large number of behaviors each household member will ideally practice for optimal health and nutrition, Applicants should plan to prioritize and layer behavioral interventions so as not to overwhelm people asking them to change too many behaviors at once.

IR 2: Improved access to MNCH, immunization and nutrition services - Access to high quality, respectful clinical services and medical interventions are critical to improving MNCHI+N outcomes - whether it is preventive care for pregnant and postpartum women, childbirth care, essential newborn care, routine vaccination, treatment for a sick child, growth monitoring and promotion, or responsive and nurturing care by caregivers and health care workers to support optimized child development. This Activity should strive to improve access to an array of integrated primary health care services using evidence-based approaches (such as integration of services, improved referral systems, and improved communication and management schemes) and monitoring their effects. Ensuring access to high quality services will improve the perception that care-seeking will result in better health outcomes. The Activity will focus on strengthening and supporting key health workforce in MNCHI+N, notably, community health workers, MNCH nurses, and relevant facility-based staff.

MNCHI+N are typically in the domain of primary health care which is delivered at the community and district levels. To succeed in improving MNCHI+N outcomes, excellent communication between community health workers, facility-based staff, and women/ patients (as well as caregivers and parents) to facilitate holistic care is needed. By ensuring clear protocols and timely referrals between mobile brigades and fixed site elements of the primary health care system, the reach of providers will be expanded and specialized resources (such as clinicians with a distinct skill set) will be used more efficiently and effectively. Additionally, enhanced support and capacity strengthening for community health workers (APEs) and traditional birth attendants will be essential to ensure the system recognizes and leverages the integral role they play in the continuum of care. USAID recognizes that to effectively reach these aims, it will be necessary to provide aligned technical assistance and coordination at the central level. Applicants should address the breakdown of planning, strategy, and policy development support that will take place at the central, provincial and district levels. Furthermore, engagement and integration of community voices in the design and implementation of activities is essential for meaningful adaptation and improvement. Therefore, engagement of community health management committees (CHMCs) will be critical in gathering and disseminating information; identifying and helping to resolve problems; and advocating on behalf of the community and patients to improve primary health care services and referrals to higher levels, as needed.

There is also enormous potential to reach “zero dose” and under-immunized children and communities through service integration of MNCHI+N. Unvaccinated and under vaccinated children often access health services for curative or other preventive services or accompany an adult seeking care at both community and health facility touchpoints. Such a visit becomes a missed opportunity if immunization is not addressed. This Activity should support reducing the number of missed opportunities by integrating MNCHI+N within primary health care planning, health registers and other record-keeping systems, and streamlining use of all encounters with the health system.

In addition to improved communication and coordination, it is also essential to have protocols and skills for administrative management of the health facilities, including resource allocation for the most critical needs. In many facilities, providers are overwhelmed with administrative and management burdens that divert attention from clinical and technical priorities. There is a need to improve administration and management capacity and resources, including budget planning and execution, development of patient management/workflow management plans, supply chain management, administrative reporting, and maintenance/upgrading of health facility infrastructure (utilizing digital platforms where feasible and desired). These improvements will enhance facility organization as well as optimize facility work and patient flows, thereby streamlining access to services.

IR 3: Improved provision of quality MNCH, immunization, and nutrition services - Access to care is an important dimension of MNCHI+N, but the quality delivery of clinical services is just as critical and requires quality improvement throughout the system. If a patient reaches a facility and is treated inadequately, needed supplies are unavailable or referrals are not made in time, confidence in the health system erodes and preventable morbidities and mortalities can occur. By creating an effective team that consistently and respectfully provides quality care, such as through QI, regularly addresses issues, increases knowledge, skills, and capacities for evidence-based health care, supports providers and the system to improve patient experiences of care, and effectively manages supply chains, quality health services can increasingly and effectively eliminate preventable deaths.

Care should be respectful, nurturing, and patient centered. These critical elements are often neglected due to resource constraints, staff burn-out, and/or lack of leadership at various levels. When patients feel respected and safe, care seeking, and follow-up care will improve for both preventive and curative clinical services. The trust that is built between patients and providers through better experiences of care also encourages greater communication and adoption of healthy behaviors. This includes considerations for language and cultural differences between patients and providers, as well as addressing documented fear of mistreatment or obligation to pay informal fees. Given the high adolescent pregnancy rates in Mozambique, it will be important to address the experience of care of this particularly vulnerable group who may hesitate to seek care for fear of stigma. Trust and information sharing is also true in ensuring HPV vaccination coverage for girls. The emphasis should be on dialogue, service quality and effective and respectful provider communication in primary care. In addition, this Activity should support trauma informed care and mental health services, especially for youth. Lastly, there is a need to encourage, role model and enforce adherence to these approaches by leadership at local, provincial, and national levels, without these aspects, newly introduced practices and skills will likely not be sustained. Quality improvement methods can facilitate these efforts and help ensure ownership and support at each of these levels.

Given that health care staff provide critical services, they need to be empowered with regular skills updates and access to information about best practices based on scientific evidence of efficacy, including new and emerging vaccines that respond to new and emerging threats (i.e. COVID-19, HPV, etc.). Access to training opportunities is limited in rural and remote settings and developing materials and platforms for remote learning could expand access to professional development opportunities.

Evidence also demonstrates the importance of QI practices as well as frequent capacity strengthening opportunities to support lasting skills development. Improving provider behaviors is not just dependent on skills building but also supportive environments, motivation, and a respectful workplace. Training alone has been shown to be ineffective in improving capacity long-term. QI approaches, mentorship, coaching, and supportive supervision models can support skills building while innovative and effective approaches from past investments should be scaled up. Technical capacity strengthening opportunities should also allow for the solicitation of feedback from health providers on their constraints and a discussion on what adaptations can be made in order to improve current practice.