Attachment J.1.pdf

RFP # 72066024R00012

Attachment J.1

USAID Santé Gouvernance Activity

ATTACHMENT J.1 – STATEMENT OF OBJECTIVE (SOO)

1. Purpose

The purpose of the USAID Santé Gouvernance contract is to empower provincial authorities to optimize the delivery of health services, to improve the health status of Congolese within their province. Health services include family planning, maternal, newborn and child health, nutrition, malaria, tuberculosis and support to build a strong and resilient public health system that can prevent, detect, and respond to emerging infectious disease threats focusing on “one health approach,” (Global Health Security-GHS). The core philosophy of the USAID Santé Gouvernance contract is to empower provinces to self-manage their health programs and increase provincial level decision-making.

The USAID Santé Gouvernance activity is an opportunity for USAID to do things differently.

Through the USAID Santé Gouvernance contract, USAID leverages its assistance as a tool to increase the province's commitment both financially to improve health governance and technically to improve health outcomes. The underlying principle is to build resilient provincial health systems; catalyze provincial commitment and capacity to mobilize domestic resources; and strengthen governance and accountability by engaging all actors (executive, legislative, private sector, civil society). Over time, as provinces’ capacities to mobilize and manage domestic resources increase, USAID’s financial contribution will decrease.

The Contractor must contribute to measurable improvements in key health outcomes.

These improvements will be measured based on indicators defined in the Plan d’Action Operationnel (PAO), in line with the provinces priorities. Indicators will be selected based on the importance they play in actually improving health outcomes. Deliverables to reach these outcomes will be developed in close collaboration with Provincial authorities and based on agreed targets set up by provincial and national documents. Funds will be disbursed when provinces reach the defined and agreed upon deliverables in the Memorandum of Understanding.

The Contractor must facilitate the discussions for expansion of funding of primary care health services within the existing framework of the Memorandum of Understanding in Lualaba and Haut Lomami, Haut Katanga, and Kasai Oriental. Expansion of services could include maternal, newborn, child health, family planning, nutrition, malaria, tuberculosis services based on the annual PAO, and their capacity to mobilize resources and deliver equitable quality health services.

The Contractor must strengthen the resilience of existing systems, the Divisions Provinciales de la Santé, the Inspectorate Provinciale de la Santé, the Health Zones, civil society organizations, communities and households. The Contractor must improve the capacity of the provincial entities to mobilize, plan and disburse funds for quality primary care services.

The Contractor must provide technical assistance to build financial and operational systems for service delivery. The Contractor will also provide technical assistance to improve client-centered care, in line with provincial priorities, targets, and protocols and guidelines. The Contractor must manage and disburse fixed price subcontracts to the DPS and provide technical assistance at provincial, health zones and service delivery points, based on https://biodiversitylinks.org/library/resources/2024-usaid-position-statement-on-one-health.pdf/view assessment of the DPS capacity to manage, plan, mobilize funds and provide quality services.

USAID recognizes that the overall objective for each province to increase its capacity to mobilize domestic resources to fund its PAO varies according to 1) potential resource base within each province; 2) capacity of the Provincial Health Divisions (Divisions Provinciales de la Santé [DPS]) to plan, manage and mobilize domestic resources for health 3) leadership of the Provincial Government and commitment to health. However, it is expected that for each province, by the end of the contract, USAID Santé Gouvernance will have contributed to the capacity of the Provinces to mobilize domestic funds to cover all the fixed-amount sub-contracts provided through the MoU.1

By the end of year 2 of the contract the Contractor, based on lessons learned during the first years of implementation, must develop a Road Map towards Self-Reliance. This Road Map must outline capacity-building steps, timelines, and milestones to ensure the DPS can independently mobilize and manage funding for health services. The Contractor must support the implementation of this Road Map towards Self-Reliance, all to build DPS and other provincial entities’ capacities to continue their efforts to mobilize resources beyond the life of the USAID Santé Gouvernance contract.

2. Background

The USAID Santé Gouvernance contract builds upon the successes and lessons learned from the Memorandum of Understanding (MOU) approach in the provinces of Lualaba and Haut Lomami. The MOU approach repositions provincial authorities at the center of governance, management and implementation of health programs. Presently, the MOU, a legal document, signed by the Governors of these two provinces, Bill and Melinda Gates Foundation (BFMG), Global Alliance for Vaccines (GAVI), and USAID seeks to empower Lualaba and H. Lomami to improve the delivery and financing of primary health care services. The MOU provides a guiding framework for increasing provincial financial resources and improving quality of all primary care health services. On a yearly basis, MOU signatories commit with the province's authorities specific levels of funding for specific health services, based on a PAO.

GAVI and BMGF are in the process of consultations and development of primary care services MOU in Haut Katanga and Kasai Oriental. It is expected that these MOUs will be signed before December 2024. USAID/DRC will start sensitizing the Haut Katanga and Kasai Oriental authorities about USAID’s intentions to also sign the legal framework, the MOU, in these two additional provinces.

Key issues to address:

● Limited provincial capacity to mobilize financing for health

The provincial health sector led by the Provincial Health Divisions (Divisions Provinciales de la Santé [DPS]) every year develops a Plan d’Actions Operationnel (PAO), which is done in collaboration with the Zonal Chief ( Chef de Zone) of the Health Zones and the DPS at Provincial level. While the PAO exists and is developed every year, it is often underfunded

1 The fixed price subcontracts will decrease overtime. It is expected that by year 5, the Province will be able to mobilize domestic resources for its specific programs.

due to mis-timing with the Province’s overall budget processes. There is a need to strengthen the capacity of Health Zone Directors (Medecin Chef) and the DPS to develop, cost, and mobilize resources for PAO in line with provincial health priorities, and in collaboration with several stakeholders (private sector, civil society, and Technical and Financial Partners (Partenaires Techniques Financiers such as World Health Organisation, UNICEF, UNFPA ).

Several institutions at the Provincial level have the responsibility to plan, budget, and allocate resources for health services, including the Provincial Ministry of Health and its DPS, Provincial Ministry of Finance, Provincial Ministry of Plan, the Governor, Ministry for Decentralization, the Decentralized Territorial Entities (Entités Territoriales Décentralisées [ETD]) and the Parliament. These institutions often operate in silos, with limited coordination and transparency in sharing levels of domestic and Partners Techniques Financiers financial contributions. There is no systematic consultation framework between the Health Zones (HZ) and the ETDs. Consultation and active engagement between the health focused planning entities and provincial budgeting and planning authorities is often missing. The limited information sharing between these two levels of planning hinder provinces’ capacities to accurately plan for financial resources for health.

Another issue that limits provincial management teams to budget effectively for the delivery of health services is the limited capacity of demand and use for quality data. Provincial management teams lack systematic approaches for reviewing health systems data across financial management, human resources, supply chain and service delivery. While the Systeme Nationale des Informations Sanitaires (SNIS) monthly data set is available online, the remainder of the data is collected and managed in ad-hoc systems without the ability to visualize health zone performance comprehensively. It is often difficult to determine the relationship between service delivery and budget execution. The Contractor, under the Technical Assistance component, must build the capacity of MoH (DPS and Health Zone Managers), Ministry of Finance (MoF) and Ministry of Plan ( MoP) and Ministry of Decentralization to use data for planning and financing health services.

● Limited quality client-centered care

A population-based survey in five provinces Equateur, Orientale, Kasai-Occidental, Kasai- Oriental, and Maniema provinces, which included data on client satisfaction, reported that only 11.8% of clients reported being satisfied with the care received while 57.7% claimed at least three reasons for dissatisfaction, including limited provider skill, waiting time, poor explanation by the provider, drug supply and equipment.

Client-centered care is grounded in tenets of care that are crucial to high-quality primary care: relationships with the people, their families, and communities being served. Client-centered care respects and responds to the needs and preferences and values of each patient; and ensures that patient values guide all clinical decisions. Client-centered care recognizes that the individual is often part of a family and a community that also makes a client's decisions to seek care. Client-centered care also emphasizes prevention and wellness, or health care rather than disease treatment. This paradigm shifts from “health facility curative services” to client, family and community centered care required for health workers to deeply understand their clients and communities. Client-centered care also requires providing quality services all along the continuum of care. Strong, effective referrals/counter referrals to services needed that effectively follow the client are needed.

● Limited consultative processes to improve health programming and governance Provincial Assemblies and members of parliament can play an important role in advocating and allocating for the release of the provincial budget, to be transparent and disseminated with the private sector, civil society and Technical and Financial Partners (Partenaires Techniques et Financiers [PTFs]. In addition to playing an active role in ensuring that the provincial budget is known, these members of parliament have a role to play on budgetary control, ensuring that the disbursement of funds for health services are done according to the voted budget. During recess, parliamentary members can also play an active role in monitoring quality of health services as defined in the provincial budget. However, the active role of the Parliamentarians in health governance to date remains limited.

The Provincial Inspectorate Division (Inspection Provinciale de la Santé [IPS]) plays an active role in controlling disbursement of equipment, medicine, financial resources, human resources available at the point of service delivery. However, as reported by the IPS, the IPS is under-funded to meet its mandate.

Civil society actors (local NGOs such as associations of midwives, youth associations, etc.)

play a critical role in increasing accountability and governance of health services management and delivery. Being so close to their communities, LNGOs deeply understand their communities and priority needs. Often government entities at all levels hesitate to seek their involvement. Local NGOs, youth groups, women groups lack the organizational and technical capacity to actively advocate with DPS regarding their communities’ priorities;

and to hold the DPS accountable for quality, equitable health service delivery.

3. Contract implementation model:

The Contractor must perform the following:

● Fixed-Price subcontracts to local institutions: Provincial Health Divisions (Divisions Provinciales de la Santé [DPS]). The Contractor must issue and manage Fixed-Price subcontract to pass-through funding to support the activities and the sustainable development of the DPS. The Fixed-Price subcontract amount will be defined on an annual basis, based on the Plan d’Action Operationnel, the provincial annual budget plan, and capacities of provinces to mobilize domestic financial resources. The annual budget plan must be developed, approved, and regularly reviewed by the provincial authorities, the Contractor, USAID and other Development Partners who might join the MOU.

To ensure that provinces have access to initial funds for programs, deliverable “zero” will be developed such as PAO approved, MOU meetings, etc. Funds have to be available at the beginning of the year, as provinces still have limited capacity to mobilize domestic resources. The balance of funds not used during the first year must be reprogrammed for the following year. During the first year of implementation, as the Provincial budgets will have been defined in 2024 for year 2025, the deliverables for the new provinces (Kasai Oriental and Haut Katanga) will be mostly defining the MoU and its annexes per program. Financial contributions to the MOU from the existing MoU provinces (Haut Lomami and Lualaba) are expected to continue.

These Fixed-Price subcontracts will finance the planning and delivery of health services within each province, all the way to the point of service delivery. Fixed-Price subcontracts will also finance innovations led by provinces and health zones. The total amount for the Fixed-Price subcontracts to the four DPS is expected to be at least 30% to 40% of the total estimated cost of the Contract with the Prime. The level of funding for these subcontracts will decrease overtime as provincial domestic funding to provincial health services increases.

● Governance, Administrative, Financial management assistance. The Contractor must provide governance and managerial, financial assistance, based on identified capacity needs of provinces to mobilize and expand funds for health programs. This technical administrative, financial, governance assistance must include improving demand and use of quality data for planning/budgeting health programs; and technical assistance to build capacity of provinces towards future self-reliance, beyond the life of the contract.

External monitoring is essential to build accountability to results. The Contractor will strengthen the monitoring/audit functions of the Inspection Provinciale de la Santé and other civil society organizations.

It is expected that this management and financial management assistance would decrease over the five years of the contract.

● Technical Assistance for improving equitable quality of services: The Contractor must provide technical assistance to the provinces to improve quality of services and community engagement based on the needs expressed by the Provinces. This technical assistance will include building core competencies and attitudes of health workers for the specified health services, strengthening monitoring systems, ensuring adherence to standards, norms, and strengthening existing social accountability systems. Under this technical assistance, the Contractor must leverage USG and other development partners’ investments to support integration of technology to improve capacity building strategies and improve monitoring and reporting of results.

Technical assistance is expected to decrease over the years as provinces build their own technical expertise.

4. Performance Objectives and Results

Objective 1: Expand Provincial Commitment and Mobilization of Domestic Financial Resources for Primary Health Care Services

The Contractor must increase provincial domestic mobilization of resources and increase provincial commitment to lead and manage a broad range of health services, such maternal newborn child health, family planning, malaria, nutrition and tuberculosis, based on the provinces’ Plan d’Action Operationnel. Expansion of services will be determined by the Provincial authorities and the Contractor, in consultation with USAID based on the Annual

Operation Plan (PAO). The Contractor must also strengthen the coordination of the One Health Platforms at provincial level to prevent, detect and rapidly respond to emerging pandemic threats.

The Contractor must build the competencies of the different Provincial and HZ entities to plan and cost health programs, to allocate and manage financial resources and strengthen accountability systems within the Provincial systems (Ministry of Finance (MoF), Ministry of Budget (MoB), Ministry of Plan (MoP). To support the DPS capacity to mobilize funds for health, the Contractor must support aligning budgeting and planning calendars between the MOH,MOF, MOB and MOP to ensure that resources are aligned with needs identified in the Plan d’Action Operationnel (PAO). The Contractor must provide technical assistance to support joint planning sessions between the Provincial Ministry of Health, Budget, Finance to streamline financial planning procedures and reduce administrative complexities.

The Contractor must issue and manage Fixed-Price subcontracts, with clear deliverables for fund disbursement to the DPS based on lessons learned from the MOUs in Lualaba and Haut Lomami. The Contractor must build upon the structures that already exist to strengthen accountability and disbursement of funds through these Fixed Price sub-contracts. The Contractor must review and revise if needed existing standards operating procedures to improve financial accountability and performance of the DPS to achieve results.

Under this Objective 1, the Contractor must attain the following results:

● IR 1.1 Edicts for funding primary care health services issued and signed by the Governor

● IR.1.2 DPS and HZ Managers capacity to develop, cost and implement PAO improved

● IR. 1.3 Yearly Fixed-price sub-contracts issued based on PAO and provincial capacities. These subcontracts will fund the delivery of several primary care services, as defined by the Province

● IR. 1.4 Transparent provincial financial management tools and disbursement systems for health from provinces to health zones strengthened

● IR. 1.5 MOU Manuals of Standard Operating Procedures revised, standardized and adopted by the four provinces

● IR 1.6. Advocacy for greater financial contributions in place including advocacy plans and building capacity of MOH to advocate with the Executive and Legislative provincial entities

Indicators:

In addition to the required indicator as stated below, the Contractor must suggest additional high level outcome indicators to measure performance for objective one:

● Percentage of funds mobilized by DPS for health programs covered by the MOU per province

Objective 2: Client-Centered Quality Care Improved

The Contractor must provide technical assistance to improve equitable access and quality of health services based on identified needs and requests from the DPS. This technical assistance must build the core competencies and attitudes of health workers, all to improve client-centered care.

The Contractor, based on the PAO priorities, must provide technical assistance to both build core competencies of health workers across the level of care (facilities and community- Relais Communautaires) and improve health workers’ attitudes to provide respectful care for all clients.

The Contractor must provide technical assistance to improve the organization and operation of the points of service delivery. The contractor must strengthen the continuum of care within a health facility or across the different levels of care. The contractor must address financial barriers that limit demand and access to health services.

The Contractor must build upon USAID prior investments in strengthening global health security. The Contractor must l strengthen coordination between human, animal and environmental health through the One Health Platform. The Contractor must provide technical assistance to strengthen Integrated Disease and Response both at health facility and community levels and strengthen Risk Communication and Community Engagement.

The Contractor, in consultation with the DPS and other health stakeholders, must facilitate the identification of indicators to measure improvement of care, specifically indicators and targets to “move the dial on key program areas contributing to poor health results, based on local context and in alignment with the National Health Development Plan 2024-2030”.

The Contractor must identify targets and validate target results in collaboration with the DPS and other Government of the Democratic Republic of Congo (GoDRC) entities, in line with the agreed PAO. By involving provincial authorities in the target-setting process, the relevance and achievability of the targets are enhanced, fostering a sense of accountability and drive to meet the mutually agreed goals. To build accountability and governance, the Contractor must ensure that the defined targets are well understood by a broad range of stakeholders (legislative, civil society, and private sector as defined under Objective 3)

Under this result, the Contractor must build on technology-based tools already developed under the MOU for Lualaba and H. Lomami to build competencies and to monitor results.

Under this Objective 2, the Contractor must attain the following results:

● IR 2.1 Core competencies of HWs to deliver quality services improved

● IR 2.2 Attitudes, communication skills of HWs improved

● IR 2.3 Access to health services by vulnerable segments of population increased

● IR 2.4 Organisation of services provided by service delivery points improved

● IR 2.5 Integrated Disease Surveillance and Response improved (both at facility and community level)

Indicators:

In addition to the three required indicators, the Contractor must suggest additional high level outcome indicators to measure performance for objective two.

● Percentage of specific services (Family Planning, immunization, maternal, newborn and child health, malaria, nutrition, tuberculosis, surveillance and response of emerging new pandemic threats) provided according to protocols

● Percentage of Health workers who provide specific services according to protocols

● Percentage of clients who shared that they received client-centered care

Objective 3: Accountability Systems In Place

The contractor must strengthen capacities of the legislative entities to enhance budget transparency, budgetary controls, and to monitor the quality of services.

The Contractor must allocate resources for the IPS to perform its functions to ensure compliance with regulatory protocols, all to increase accountability. The Contractor must also build the IPS capacity to perform its audit functions.

The Contractor must improve social accountability systems by increasing civil society active participation in both the planning for health programs (PAO level) and implementation (quality of services). The Contractor must ensure that local civil society organizations understand their roles and responsibilities as well as their rights in provincial and local health accountability forums.

The Contractor must identify promising local civil society organizations in each province. The Contractor must manage a grants under contract fund to disburse grants, starting year two, to the identified local civil society organizations to strengthen governance and accountability for health within each province.

Under this Objective 3, the Contractor must attain the following results:

● IR 3.1 Governance, monitoring and control systems for the MOU implementation strengthened.

● IR. 3.2 Parliamentary engagement for health increased

● IR 3.3 IPS capacity to conduct audits and follow up on findings improved

● IR 3.4. Local NGO capacity for health governance strengthened

● IR 3.5 Civil society engagement for planning, allocation and implementation domestic financial resources increased

Indicators

In addition to the two required indicators, the Contractor must suggest additional high level outcome indicators to measure performance for objective three.

● Number of Core Group meetings which include LNGOs

● Number of field monitoring visits of the MOU implementation that include

Parliamentarians.

Provinces: Lualaba, Haut Lomami, Haut Katanga, and Kasai Oriental

5. Guiding Principles for the USAID Santé Gouvernance Activity:

● Gender Equality: USAID is committed to promoting gender equity and equality and to ensure its program advances the rights and uphold the dignity of all persons.

Through the Gender Equality and Women's Empowerment Policy, USAID affirms that gender equality and women’s and girls’ empowerment are fundamental for the realization of human rights and key to effective and sustainable development outcomes, and provides its vision to advance that aim.The Contractor must strengthen provincial health systems to understand and engage with gender dynamics to ensure that women and girls have equitable access and use of quality primary health services.

● Inclusive Development: The Contractor must take an intentional and proactive inclusive development approach. This approach must ensure that all people, including marginalized and vulnerable groups including women, adolescents, people living with disabilities, vulnerable children, or groups facing discrimination, are included and can participate fully in, and benefit equally from the Activity. The Contractor must build the leadership of the provincial entities and other stakeholders in developing and implementing socially inclusive health programs, where health interventions are tailored to ensure equitable access to quality services; where health providers also have equitable access to professional development opportunities, and where collaboration and coordination across sectors (social protection, legal protection, health, economic strengthening, etc.) is strengthened. Through the grants-under contract, the Contractor must increase citizens participation in improving governance of health programs managed by the

DPS.

● Health Governance and Accountability: The Contractor must build accountability at all levels, provincial, health zones, health delivery points and communities.

Specifically, DPS will be held accountable for mutually agreed deliverables as delineated in the fixed price subcontracts before receiving funding. Evidence-based promising practices, and lessons learned must be shared at provincial level between provincial entities (DPS, IPS, MoU participants, civil society, and donors) and also with stakeholders beyond the health sector such as the Governor, representatives of the Provincial Ministry of Finance, the Parlement and others to strengthen governance and accountability in the health sector. The Contractor must promote greater transparency and accountability for improved health outcomes also by strengthening civil society engagement and social accountability systems through grants under contract.

● Private Sector Engagement (PSE): The Activity aligns with the USAID Private Sector Engagement Policy and aligns with DRC Plan National de Développement Sanitaire et de Prevoyance Sociale (PNDS-PS 2024-2033) that recognises that the private sector plays an increasingly important role in delivering primary health services. The Activity will build the capacity of the DPS and other provincial entities to engage and coordinate with the health private sector, strengthening PSE during the development of the PAO. The Contractor must facilitate collaboration and coordination across multi-sector health actors such as the public health sector (MOH, DPS, IPS, Health Zones), civil society and private sector to expand equitable access and use of primary health services.

● Adaptive Management: The Contractor must make best use of the latest principles in monitoring, evaluation, and learning in order to set and achieve targets, fulfill https://www.usaid.gov/gender-policy https://www.usaid.gov/gender-policy objectives, and demonstrate outcomes of development efforts undertaken as part of this award. Complexity-aware monitoring approaches, as well as good practices in collaborating, learning, and adapting (CLA), are vital to ensure adaptive programming that responds to changing circumstances, new knowledge, and new evidence. The Contractor must systematically document the implementation of the MoU approach detailing enabling factors and challenges. This documentation is critical to building sustainable resilient provincial health systems (DPS, IPS, Health Zones and service delivery points), and critical to build a commitment towards the MoUs approach beyond the four selected provinces.

● Humanitarian-Development-Peace coherence: USAID Santé Gouvernance aligns with the USAID Resilience Policy.2 The Contractor must improve collaboration, coordination and learning across sectors beyond health that all contribute to improving citizens’ wellbeing and the nexus between humanitarian and development responses.

● Conflict and Climate Sensitivity: The Contractor must adapt its implementation strategies based on a deep understanding of the contextual realities of each province. Marginalization and discrimination are some of the most powerful factors that reinforce conflict dynamics and exacerbate security concerns. The Contractor, working closely with the DPS and other provincial entities (Governor, Parlement), civil society, private sector and donors, needs to strengthen systems to improve equitable access and use of health services, including for the most marginalized segments of population. Ensuring equitable access and use of quality primary care services contributes to preventing conflicts. The Contractor must integrate “Do NO HARM” in its implementation.

DRC is highly vulnerable to climate change. Climate shocks increase the vulnerability of marginalized groups to malnutrition, illnesses, hunger and violence including gender-based violence. The Contractor must reinforce local systems at all levels to plan and mitigate the impact of climate change on accessing and using essential health services.

[End of Attachment J.1]

2https://www.usaid.gov/sites/default/files/2024- 06/USAID3090_USAID%20Resilience%20Policy_062524_WEB%28508c%29.pdf https://www.usaid.gov/sites/default/files/2024-06/USAID3090_USAID%20Resilience%20Policy_062524_WEB%28508c%29.pdf https://www.usaid.gov/sites/default/files/2024-06/USAID3090_USAID%20Resilience%20Policy_062524_WEB%28508c%29.pdf

ATTACHMENT J.1 – STATEMENT OF OBJECTIVE (SOO)