Draft RFP_HE176-09-005.DOC

OPENING DATE:

Wednesday, January 15, 2009

CLOSING DATE:

Thursday, January 29, 2009

CLOSING TIME:

10:00am, Almaty Time

SUBJECT:

Request for Proposal (RFP) No. HE176-09-005 - DRAFT VERSION Health Improvement Project for Central Asia Dear Sir/Madam:

The United States Government, represented by the United States Agency for International Development Regional Mission to Central Asia (USAID/CAR), is publishing the subject RFP as a DRAFT, in order to obtain comments/input from all public and private interested parties. Your comments/inputs about this draft RFP are requested, and may be taken into consideration for the preparation of the final RFP.

All types of eligible organizations and firms are strongly encouraged to review the document, provide comments, and consider submitting offers in response to the resulting final RFP (solicitation).

Interested parties are encouraged to submit comments and input. Please send comments at e-mail AlmatyAASolicitations@usaid.gov by the closing date as specified above.

USAID/CAR anticipates posting the final RFP o/a February 19, 2009 with the closing date o/a April 4, 2009.

USAID/CAR will conduct a Pre-Solicitation Conference on March 9, 2009. Representatives from the USAID/CAR mission will be made available for a question & answer (Q&A) session from TBD pm until TBD pm.

Street Location of Pre-Solicitation Conference:

1300 Pennsylvania Ave., N.W.

Washington, D.C. 20523

Room :TBD

Point of Contact: TBD

Telephone: TBD

USAID/CAR is not requesting proposals at this time. Any proposal that is received in response to this DRAFT RFP will be discarded prior to issuance of the RFP. USAID/CAR reserves the right not to incorporate any and all comments into the final RFP, or even issue a final RFP.

Sincerely, John Griffin Regional Contracting Officer

Table of Contents Page

6PART I - THE SCHEDULE

6SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

6B.1 PURPOSE

6B.2 CONTRACT TYPE

6B.3 ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT

6B.4 PRICE SCHEDULE

7B.5 INDIRECT COSTS (DEC 1997)

7B.6 CEILING ON INDIRECT COST RATES (DEC 1997)

7B.7 COST REIMBURSABLE

8SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

44SECTION D – BRANDING AND MARKING

44D.1 752.7009 MARKING (Jan 1993)

44D.2 BRANDING AND MARKING POLICY

44D.3 BRANDING STRATEGY

45D.4 BRANDING IMPLEMENTATION PLAN AND MARKING PLAN

46SECTION E - INSPECTION AND ACCEPTANCE

46E.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

46E.2 INSPECTION AND ACCEPTANCE

47SECTION F - DELIVERIES OR PERFORMANCE

47F.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

47F.2 PERIOD OF PERFORMANCE

47F.3 PERFORMANCE STANDARDS

47F.4 REPORTS AND DELIVERABLES OR OUTPUTS

48F.5 752.242-70 PERIODIC PROGRESS REPORTS (July 1998)

49F.6 752.7005 SUBMISSION REQUIREMENTS FOR DEVELOPMENT EXPERIENCE DOCUMENTS (JAN 2004)

49F.7 KEY PERSONNEL

51SECTION G - CONTRACT ADMINISTRATION DATA

51G.1 AIDAR 752.7003 DOCUMENTATION FOR PAYMENT (NOV 1998)

52G.2 ADMINISTRATIVE CONTRACTING OFFICE

52G.3 COGNIZANT TECHNICAL OFFICER (CTO)

52G.4 TECHNICAL DIRECTIONS/RELATIONSHIP WITH USAID

54G.5 PAYING OFFICE

54G.6 ACCOUNTING AND APPROPRIATION DATA

55SECTION H - SPECIAL CONTRACT REQUIREMENTS

55H.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

55H.2 AIDAR 752.7004 EMERGENCY LOCATOR INFORMATION (JUL 1997)

55H.3

752.228-70 MEDICAL EVACUATION (MEDEVAC) SERVICES (JUL 2007)

56H.4 AUTHORIZED GEOGRAPHIC CODE

56H.5 NONEXPENDABLE PROPERTY PURCHASES AND INFORMATION TECHNOLOGY RESOURCES

56H.6 LOGISTIC SUPPORT

56H.7 LANGUAGE REQUIREMENTS

56H.8 SUBCONTRACTING PLAN AND THE SF 294 - SUBCONTRACTING REPORT FOR INDIVIDUAL CONTRACTS AND SF 295 - SUMMARY CONTRACTING REPORT

56H.9 EXECUTIVE ORDER ON TERRORISM FINANCING (FEB 2002)

57H.10 REPORTING OF FOREIGN TAXES

57H.11 USAID DISABILITY POLICY - ACQUISITION (DECEMBER 2004)

58H.12 AIDAR 752.225-70 SOURCE, ORIGIN AND NATIONALITY REQUIREMENTS (FEB 1997)

59H.13 GRANTS UNDER CONTRACTS

59H.14 752.7007 PERSONNEL COMPENSATION (JUL 2007)

60SECTION I - CONTRACT CLAUSES

60I.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

61I.2 52.204-7 CENTRAL CONTRACTOR REGISTRATION (JUL 2006)

63I.3 52.219-23 NOTICE OF PRICE EVALUATION ADJUSTMENT FOR SMALL DISADVANTAGED BUSINESS CONCERNS (SEP 2005)

64I.4 52.232-25 PROMPT PAYMENT (OCT 2003)

68I.5 52.222-39 NOTIFICATION OF EMPLOYEE RIGHTS CONCERNING PAYMENT OF UNION DUES OR FEES (DEC 2004)

69I.6 FAR 52.222-50 COMBATING TRAFFICKING IN PERSONS (AUG 2007)

71I.7 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

71I.8 AIDAR 752.7032 INTERNATIONAL TRAVEL APPROVAL AND NOTIFICATION REQUIREMENTS (JAN 1990)

72SECTION J - LIST OF ATTACHMENTS

74SECTION K - REPRESENTATIONS, CERTIFICATIONS AND

OTHER STATEMENTS OF OFFERORS

74K.2 52.204-8 ANNUAL REPRESENTATIONS AND CERTIFICATIONS (JAN 2006)

75K.3 INSURANCE - IMMUNITY FROM TORT LIABILITY

75K.4 52.230-1 COST ACCOUNTING STANDARDS NOTICES AND CERTIFICATION (JUNE 2000)

77K.5 52.230-7 PROPOSAL DISCLOSURE—COST ACCOUNTING PRACTICE CHANGES (APR 2005)

77K.6 SIGNATURE

78SECTION L - INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS

78L.1 52.215-1 INSTRUCTIONS TO OFFERORS – COMPETITIVE ACQUISITION (JAN 2004)

81L.2 52.216-1 TYPE OF CONTRACT (APR 1984)

81L.3 52.233-2 SERVICE OF PROTEST (SEP 2006)

82L.4 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998)

82L.5 GENERAL INSTRUCTIONS TO OFFERORS

83L.6 INSTRUCTIONS FOR THE PREPARATION OF THE TECHNICAL PROPOSAL

85L.8 INSTRUCTIONS FOR THE PREPARATION OF THE COST PROPOSAL

87L.9 PARTICIPANT TRAINING

89SECTION M - EVALUATION FACTORS FOR AWARD

89M.1 NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY REFERENCE

89M.2 EVALUATION CRITERIA

92M.3 DETERMINATION OF THE COMPETITVE RANGE AND CONTRACT AWARD

92M.4 CONTRACTING WITH SMALL BUSINESS CONCERNS AND DISADVANTAGED ENTERPRISES

93ATTACHMENTS

93ATTACHMENT 1 IDENTIFICATION OF PRINCIPAL GEOGRAPHIC CODE NUMBERS

94ATTACHMENT 2 USAID FORM 1420-17 - CONTRACTOR BIOGRAPHICAL DATA SHEET

97ATTACHMENT 3 SF LLL - DISCLOSURE OF LOBBYING ACTIVITIES

101ATTACHMENT 4 CONTRACTOR PERFORMANCE REPORT SHORT FORM

102ATTACHMENT 5 SAMPLE SMALL BUSINESS SUBCONTRACTING PLAN

106ATTACHMENT 6 ENVIRONMENTAL COMPLIANCE REQUIREMENTS FOR HIP

108ATTACHMENT 7 PARTICIPANT TRAINING REPORT

111ATTACHMENT 8 - USAID/CAR Results Framework for Health

111ATTACHMENT 9 Analysis of status of Infection Prevention and Control (IPC) measures in hospitals in Kyrgyzstan

111ATTACHMENT 10 WHO Policy on TB Infection Control (available February 2009)

111ATTACHMENT 11 ZdravPlusII Mid-Term Evaluation Report

111ATTACHMENT 12 USAID supported activities and contact information

111ATTACHMENT 13 Table of Global Fund grants

111ATTACHMENT 14 Country strategies (multiple documents)

111ATTACHMENT 15 ENVIRONMENTAL COMPLIANCE FACESHEET FOR THE INITIAL ENVIRONMENTAL EXAMINATION (IEE)

111ATTACHMENT 16 Conceptual Paper: A Health Systems Approach to TB Infection Control in Central Asia

111(available February 2009)

111ATTACHMENT 17 List of Continuous Quality Improvement (CQI) sites

112ATTACHMENT 18 Additional Website Links

113ATTACHMENT 19 Template Marking and Implementation Plans

PART I - THE SCHEDULE

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

B.1 PURPOSE

The purpose of this contract is to provide technical assistance, training, equipment and commodities to assist the Central Asian republics (CAR) to improve the quality, scope, and coordination of health services. By incorporating modern quality improvement techniques and evidence-based international standards into ongoing reforms of health systems, this program will assist Central Asian countries to improve their management, financing, and implementation of medical services provided for tuberculosis (TB), HIV/AIDS, and primary health care (PHC), including maternal and child health (MCH) services.

B.2 CONTRACT TYPE

This is a Cost-Plus-Fixed-Fee (CPFF) completion contract. For the consideration set forth below, the Contractor shall provide the deliverables or outputs described in Sections C and F in accordance with the performance standards specified in Sections C and F.

B.3 ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT

(a) The estimated cost for the performance of the work required hereunder, exclusive of fixed fee, if any, is TBD. The fixed fee, if any, is TBD. The estimated cost plus fixed fee, if any, is TBD.

(b) Within the estimated cost plus fixed fee (if any) specified in paragraph (a) above, the amount currently obligated and available for reimbursement of allowable costs incurred by the Contractor (and payment of fee, if any) for performance hereunder is TBD. The Contractor shall not exceed the aforesaid obligated amount.

(c) Funds obligated hereunder are anticipated to be sufficient through TBD.

B.4 PRICE SCHEDULE

Base Period

a. Total Cost

b. Fixed Fee

c. Total Cost + Fixed Fee

Option Year 4

a. Total Cost

Option Year 5

a. Total Cost

B.5 INDIRECT COSTS (DEC 1997)

Pending establishment of revised provisional or final indirect cost rates, allowable indirect costs shall be reimbursed on the basis of the following negotiated provisional or predetermined rates and the appropriate bases:

Description

Rate Base Type Period

1/

2/

2/

1/Base of Application:

Type of Rate: Provisional Period:

2/Base of Application:

Type of Rate: Provisional Period:

B.6 CEILING ON INDIRECT COST RATES (DEC 1997)

(1) Reimbursement for indirect costs shall be at the lower of the negotiated final (or predetermined) rates or the following ceiling rates:

Description

Rate

Base Period

Overhead

TBD

Life of the contract;

(2) The Government will not be obligated to pay any additional amount should the final indirect cost rates exceed the negotiated ceiling rates. If the final indirect cost rates are less than the negotiated ceiling rates, the negotiated rates will be reduced to conform with the lower rates.

(3) This understanding shall not change any monetary ceiling, obligation, or specific cost allowance or disallowance. Any changes in classifying or allocating indirect costs requires the prior written approval of the Contracting Officer.

B.7 COST REIMBURSABLE

The U.S. dollar costs allowable shall be limited to reasonable, allocable and necessary costs determined in accordance with FAR 52.216-7, Allowable Cost and Payment, FAR 52.216-8, Fixed Fee, if applicable, and AIDAR 752.7003, Documentation for Payment.

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

Health Improvement Project for Central Asia

2009 – 2014

SECTION C: BACKGROUND/SPECIFICATIONS/STATEMENT OF WORK

C.1. BACKGROUND

(a) Overview

The goal of this contract is to improve the capacity of the public health systems of Central Asia to better meet the health needs of vulnerable groups. The project’s strategy for achieving this goal is to introduce or institutionalize quality improvement methodologies at all levels of health services management and empower the community to respond to health needs.

The Health Improvement Project (HIP) will provide technical assistance, training, equipment and commodities to assist the Central Asian republics (CAR) to improve the quality, scope, and coordination of health services. By incorporating modern quality improvement techniques and evidence-based international standards into ongoing reforms of health systems, this program will assist Central Asian countries to improve their management, financing, and implementation of health services related to tuberculosis (TB), HIV/AIDS, and primary health care (PHC), including maternal and child health (MCH) services. The HIP will continue to empower the community through knowledge and behavior change to improve the quality of services and personal wellbeing. The HIP will build upon the successes of USAID health reform activities implemented over the past 10 years throughout Central Asia by continuing to improve access to quality public health and primary health care services.

As with previous USAID activities, the new project will work with national stakeholders and other donors to avoid duplication and ensure cohesiveness of the program. The HIP will take into account the reforms and national programs that are currently taking place in Central Asia and will complement and provide unique contributions to the reform process.

(b) Overarching Problems and Challenges

While the countries of Central Asia are at varying points on the development continuum with different resources, all CAR share the challenge of continuing to reform inefficient and unresponsive Soviet models into working health systems. Public health expenditures in all CAR are less than 4% of GDP (Kazakhstan 3.3% - Tajikistan 1%). Health systems inherited from Soviet times include vertical structures for HIV, TB, sexually transmitted infections, drug treatment, and blood safety services, with little or no coordination between them. Although progress has been made in restructuring health systems so they are more efficient and improving health services to better meet the needs of Central Asians, this progress varies widely by country, and the benefits of health reforms have not yet translated into improved health outcomes on a national scale. This is particularly true for poor, rural, or otherwise vulnerable populations.

USAID’s Europe & Eurasia Health Vulnerability Analysis for 2007 described Central Asia as the most vulnerable sub-region of Europe & Eurasia (E&E). Central Asia is the only sub-region that has experienced a reduction in life expectancy since 2001 (dropping from 67.5 to 65.6 years). In fact, the life expectancy in Turkmenistan (61 years) is the lowest in the entire E&E region, and is comparable with rates in Yemen and Pakistan. While the countries in Central Asia have varying levels of resources and economic development, payment for health services represents a significant expense throughout the region. Tajikistan, the poorest of the countries, has the highest out-of-pocket payments where individuals are responsible for covering 76% of healthcare costs.

Maternal mortality is the single greatest cause of female adult mortality throughout CAR, with the largest increase in adult female mortality taking place in Tajikistan. While the majority of women give birth in health facilities with trained providers, the quality of delivery services is very poor. Almost all five countries have declared an intention to implement the WHO-recommended international definition of live birth, but only Kyrgyzstan has nationwide implementation. Central Asia exhibits the highest levels of under-five mortality in the E&E region. Child mortality ranges from 36.3/1000 in Kazakhstan to 89/1000 in Tajikistan. Stunting due to malnutrition has been found to be a significant problem in all of the countries, and rates of appropriate breastfeeding and complimentary feeding are low.

Tuberculosis contributes to an estimated 1,100 deaths each year in the Central Asian republics, and the existence of multi-drug-resistant (MDR) TB is a huge challenge for health systems in the region. MDR TB levels are among the highest in the world (23% for Kazakhstan, 18% for Uzbekistan for new cases). Prisons are settings with extremely high rates of TB and MDR TB and sources of transmission. Rising prevalence of HIV increases opportunities for co-infection and threatens to further destabilize TB control.

In 2004, the World Bank described the HIV/AIDS situation in Eastern Europe and Central Asia as the fastest growing HIV/AIDS epidemic in the world. Driven by injecting drug use, high rates of HIV prevalence can be observed among the most at risk populations (MARPs) along the drug trafficking routes that run from Afghanistan through Tajikistan, Uzbekistan, the Kyrgyz Republic, and Kazakhstan. Sentinel surveillance conducted by the U.S. Centers for Disease Control and Prevention (CDC) in 2007 found prevalence of HIV to be as high as 34% among injecting drug users and 16% among sex workers in parts of Uzbekistan, and 8.4% among prisoners in Tajikistan. As noted in the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) 2006 report on Eastern Europe and Central Asia, another worrying trend is the number of young people infected. Approximately 75% of new infections over the previous five years have occurred in people younger than thirty years of age. While still considered to be a concentrated epidemic, extremely high rates among MARPs as well as repeated healthcare-associated blood borne outbreaks of infections indicate a potential for future spread of HIV between populations. The marginalized status of populations most at risk for HIV makes data difficult to access and requires very targeted prevention activities.

In 2006-2008, outbreaks of HIV and AIDS were discovered among hospitalized children in Kazakhstan, Uzbekistan and the Kyrgyz Republic. Investigations determined that these outbreaks were due to contamination of the blood supply and re-use of medical equipment. A recent study conducted by USAID in health facilities in the Kyrgyz Republic identified seven major gaps in infection prevention and control practices, including overuse of blood products, unsafe injections, and inadequate management of supplies. Due to the regional practice of family/ replacement donations, sometimes involving paid donors, as well as poor screening capacity, blood products available for clinical use in all five countries have been found to be contaminated. The quality of laboratory testing for HIV and hepatitis is an issue across the region. A recent World Bank/ CDC study of blood services in Central Asian health systems revealed undetected cases of HIV and hepatitis B and C in blood and blood products that had been screened in local laboratories for these viruses.

High rates of migration, particularly from Tajikistan and Kyrgyzstan, to destinations within and outside the region complicate management and measurement of the TB and HIV epidemics. For much of the year entire villages in rural areas are inhabited only by women and children, as men seek work in Russia and Kazakhstan, often staying there for long periods of time. While migrants generally are considered to be a risk group for HIV and TB in Central Asia, little prevalence data is available. Reaching these itinerate workers with TB and HIV services, both in their countries of origin (Kyrgyzstan, Tajikistan, and Uzbekistan) and in their temporary residences in Kazakhstan, remains a challenge not adequately addressed in the region.

(c) USAID’s Response

In 1994, USAID funded ZdravReform, the first in a series of three projects to help the CAR to reform their health care systems. The first project offered assistance to Kyrgyzstan, Kazakhstan, Turkmenistan and Uzbekistan. Now in its third contract period, the Quality Public Health and Primary Health Care in Central Asia (ZdravPlus II) project is funded through 2009 and includes Tajikistan in the scope of work. (http://www.zplus.kz)

The goal of this assistance has been the same since 1994: to assist the governments of Central Asia to restructure their primary care delivery systems and restructure budgets to provide more support for primary health care to improve health status through a strengthened system of primary care. Expected outcomes included the introduction of modern clinical protocols, the implementation of new provider payment methods, and increasing consumer choice. With the design of ZdravPlusII in 2004, USAID sought to address the need for medical leadership to accept and promote changes in clinical practices to improve both the quality and the scope of primary health care. The project broadly promoted evidence-based medicine to medical leaders and the development and implementation of new clinical practice guidelines in addition to continuing support for family or general practice and specific service delivery improvements in priority program areas.

USAID has been assisting CAR governments with their response to the TB epidemic since 1997. Priority has been placed upon demonstrating, improving and expanding DOTS in all five countries. Current programs work with Central Asian governments to improve TB data collection, quality, and analysis by capacity building on the use of TB surveillance and case management system software. USAID also supports Central Asian governments to develop external quality assurance systems with the TB laboratory network; strengthen legislative and regulatory frameworks related to TB; build human and systems capacity; and support community advocacy and mobilization. (http://www.hope-car.org)

Beginning in December 2008, USAID’s Tuberculosis Control Assistance Program (TB CAP) program will build the capacity of CAR to address MDR-TB. In Kazakhstan, TB CAP will support the Ministry of Health in expanding MDR TB case management services throughout Almaty oblast, and to other oblasts. It will also upgrade the existing MDR TB treatment facility in Almaty, in conjunction with the National TB Program, to a regional center for the continuing education of Ministry of Health staff from all five CAR on how to adapt best practice models to meet the needs of each specific national health system. The project will also create a mechanism for the sustainable provision of social support to patients and their families; this includes penitentiary system patients, as well as those making the transition between the prison and civilian systems. These social support services are designed to help ensure that MDR TB patients do not default from treatment, which is a crucial factor in slowing the spread of MDR TB throughout populations. (http://www.tbcta.org/TB_CAP/)

USAID’s HIV programs have provided assistance to four Central Asian countries with application to and management of HIV grants from the GFATM. USAID’s CAPACITY program in all five CAR helps improve monitoring and evaluation, supports better communication with stakeholders, develops the capacity of local non-governmental organizations, and helps orient outreach activities toward MARPs. The Drug Demand Reduction Program introduced and tested several effective new models for working with MARPs and populations at risk for initiating injecting drug use, to reduce both drug use and the transmission of HIV, including drug demand reduction; “sister-to-sister” outreach among sex workers; drug-free treatment and rehabilitation; education and referral of migrants; treatment readiness for drug users; drug-free social spaces; “break the cycle” counseling to prevent current drug users from encouraging pre-injectors to initiate; youth positive development; and the unique identifier code, now successfully used for monitoring and surveillance of MARP in several CAR by government and donor-funded programs in several sectors. CAPACITY initiated model sites for coordinated treatment of TB/HIV patients in four countries, and is currently scaling up this program nationwide in the Kyrgyz Republic. (http://www.capacityproject.info, http://www.ddrprogram.org) USAID’s Healthy Family Project worked to improve the maternal, child and reproductive health of the populations of southern Uzbekistan, Tajikistan and Kyrgyzstan, and portions of Turkmenistan. Project activities include safe motherhood interventions, including normal delivery, complications management and life saving skills training; child health activities, including community- and hospital-based integrated management of childhood illnesses (IMCI); development of infection prevention guidelines for facilities and health care workers in limited resource settings; and a village pharmacy program. The project placed particular emphasis on health promotion activities aimed at increasing knowledge of quality reproductive and maternal and child health care, and reached more than 1,158,601 women of reproductive age and children under 5 with health messages.

With the design of the HIP, USAID seeks to build upon the success of past reform projects, by combining systems work with specific interventions in the areas of HIV/AIDS, TB, and PHC that target vulnerable groups. The past strategy of promoting Evidence Based Medicine (EBM) overall while demonstrating examples of excellence will be expanded and adjusted, so that EBM, Evidence Based Practice (EBP) and the principles of quality improvement themselves become institutionalized. (List of USAID activities)

(d) USAID/CAR Results Framework for Health

In 2008, USAID’s Office of Health developed a new Results Framework for Health Program Planning. The Office’s Assistance Objective is “Central Asian Public Health Systems Better Meet the Health Needs of Vulnerable Groups”. To achieve the Assistance Objective, USAID/CAR will conduct activities that address four Intermediate Results and sub-results:

Intermediate Result 1: Creating a Safer Medical Environment

· IR1.1: Blood Supply Improved

· IR1.2: Infection Prevention and Control Improved

Intermediate Result 2: Strengthening Public Health Capacity

· IR2.1: Methods for Improving Quality Care Institutionalized

· IR2.2: Management improved

· IR 2.3: Lab Quality Assurance Measures Expanded

· IR 2.4: Disease Surveillance Improved

· IR 2.5: Human Resources Development Supported

· IR 2.6: Data Better Used for Decision Making

Intermediate Result 3: Improving Quality of Health Services

· IR3.1: Methods for Improving Quality Care Institutionalized

· IR3.2: Continuum of Care Improved

· IR3.3: Licensing and Accreditation Measures Established

Intermediate Result 4: Empowering Civil Society to Better Respond to Health Needs

· IR4.1: Methods for Improving Quality Care Institutionalized

· IR4.2: Professional Associations More Sustainable

· IR4.3: Outreach to Vulnerable Groups Supported

· IR 4.4: Community Action for Health Engaged

(e) Donor Activities in CAR

The World Bank (WB) and the Asian Development Bank (ADB) are important USAID partners in supporting health reform in Central Asia. In Uzbekistan, reform efforts are assisted with loan projects from both banks, which provide $40 million each in loan funding. The WB loan is intended to facilitate the health reform process and the ADB loan focuses on strengthening maternal and child health services. The work of the two banks is harmonized through a Joint Project Implementation Bureau. In the Kyrgyz Republic, the WB leads a group of donors, including the ADB, in support of the Sector Wide Approach (SWAp) that channels external donor resources in support of a common national health reform program, Manas Taalimi (MT). Both banks support health systems reform activities in Tajikistan through separate projects, although a SWAp is currently being discussed for reforms in that country, as well. The WB recently signed an agreement with the government of Kazakhstan for joint funding of the new Health Sector Technology Transfer and Institutional Reform Project, which will expand and continue health reforms supported by USAID. The WB is currently designing new health reform programs for Tajikistan and Uzbekistan. In all Central Asian countries except Kazakhstan, WB funds activities to prepare for outbreaks of avian influenza. ADB supports regional coordination and technical assistance on avian influenza preparedness in all Central Asian countries but Turkmenistan. The WB also supports a regional program to fight HIV/AIDS, the Central Asian AIDS Control Project (CAAP), which builds the capacity of NGOs and government institutions for prevention and treatment and supports regional coordination at the highest levels of government.

GFATM grants for TB and HIV for all rounds including the latest Round 8 total $392 million for four countries of the region. Turkmenistan applied in Rounds 6 and 8 for TB funds but was rejected. HIV grants assist with implementation of National HIV/AIDS Control Strategies to expand HIV prevention, care and treatment services in the region. In Kazakhstan, the grant from the Round 7 of the Global Fund will implement programs that have been developed by USAID funded DDRP program in Tajikistan, Uzbekistan and Kyrgyzstan. The grants for TB will help expand prevention and treatment of TB program in the region including improved diagnosis and treatment of MDR TB.

Bilateral donors in the region that support overall health reform, primary health care improvement, or maternal and child health include SDC (the Swiss Agency for Development and Cooperation), Sida (The Swedish International Development Agency), the European Union, JICA (Japanese International Cooperation Agency), TICA (Turkish International Cooperation Agency), and DfID (The Department for International Development). DfID and KfW (The German Development Bank) also support specific programs on TB and HIV. KfW supports reproductive health in Uzbekistan.

UN agencies active in the region include UNODC, UNDP, UNAIDS, UNFPA, UNICEF, and WHO in all five countries. The UN works with all governments to support National AIDS Control Programs and mother, child and reproductive health and family planning programs.

(f) Overall Strategy/Core Operating Principles

1. Regional Strategy with Country Specific Activities

USAID/CAR is committed to promoting regional coordination between the CAR on priority cross-border health issues such as HIV and services for migrants. The Mission intends to promote regional coordination through creating and building the capacity of regional entities where possible. USAID/CAR strongly supports regional sharing of lessons learned, best practices, and technical expertise for all areas within health. However, the Mission also acknowledges that each country in the region has developed at different rates and now has differing needs and priorities. While health needs tend to be the most similar of the development priorities among the CAR countries, an effective regional program will be required to develop country-specific plans.

The HIP has been designed as a regional program with specific and different requirements for each of the five Central Asian countries. USAID/CAR expects the contractor to incorporate the strategic advantage of regional management for improved cost effectiveness and attract high-quality technical expertise to the region. It is also expected that programs for each country be tailored to the specific needs and changing situations of that country, and that appropriate technical and administrative support will be available to HIP staff in each country office. Technical expertise, while regional, is expected to be sufficient to meet the needs of all five countries. USAID/CAR also expects the contractor to provide creative solutions to management challenges which will enable each country office to develop a certain level of autonomy and work closely with USAID country branch offices to efficiently respond to needs as they arise.

As a result of shifting budget priorities and funding, the HIP will need to prioritize activities to achieve maximum impact with its interventions. The contractor will need to balance broader health system strengthening needs with USAID funding realities and adopt innovative and creative strategies to meet these important objectives.

Throughout the Statement of Work and in related attachments, countries are listed in alphabetical order, not in order of expected level of effort. The HIP’s greatest level of effort will be in Tajikistan (27%), followed by approximately equal levels of effort in Kyrgyzstan and Uzbekistan (23% each), Kazakhstan (17%), and finally Turkmenistan (10%).

2. US Government (USG) priorities

This program will conduct activities and will receive funding through five program elements included under the Health Program Area in the U.S. Foreign Assistance Framework: HIV/AIDS; TB; MCH; Other Public Health Threats; and Family Planning/ Reproductive Health. (See http://www.state.gov/documents/organization/93447.pdf for program element descriptions.) While activities in all of these categories will be implemented under the HIP, they will contribute towards achieving four Intermediate Results (IRs) listed in the results framework and described in Section C.2. (USAID/CAR Results Framework)

The contractor will also support three USG priorities:

· USAID’s Tuberculosis Program USAID has responded to the emergence of TB and MDR-TB around the world. All Central Asian countries are a priority in TB for USAID and are included among WHO’s 25 priority countries for MDR-TB. (http://asia.usaid.gov/our_work/global_health/id/tuberculosis/expanded_response4.html)

· USAID’s Maternal & Child Health and Nutrition Program: This strategic approach, developed in early 2008, prioritizes 30 countries around the globe for USAID MCH programming. Tajikistan is included among the priority countries. (http://www.usaid.gov/our_work/global_health/mch/publications/mch_report.html)

· The President’s Emergency Plan for AIDS Relief (PEPFAR): This initiative, developed in 2003 and coordinated by the Office of the Global AIDS Coordinator of the U.S Department of State, involves USG country teams (i.e. Department of State, USAID, the U.S Centers for Disease Control & Prevention, Department of Defense, and Peace Corps) to help countries provide HIV prevention, treatment, and care services. (http://www.pepfar.org)

3. Bottom-Up, Top-Down Approach

The HIP activities in each country are expected to be implemented simultaneously at two levels: policy assistance and capacity building of national institutions for supervision and planning; and targeted local interventions to demonstrate best practices and tailor activities to the Central Asian context. Any local interventions (“pilots”) should be well coordinated to provide a comprehensive health systems approach. HIP pilots should correspond to pilot interventions of other USAID projects, by sharing geographic target areas in order to model system-wide improvements. The contractor will work with national governments to scale up interventions successfully piloted by previous USAID projects. For the purpose of this RFP, implementing at scale refers to increasing the volume of outputs and enlarging the scope of activities to reach more people. The contractor will work closely with CAR governments to promote the eventual implementation of all successful innovations at scale.

4. Focus on Quality Improvement

One of the primary objectives and core functions of the HIP is to improve the quality of health services throughout the CAR. The program should take a top to bottom approach for quality improvement that includes improving the quality of clinical outcomes (EBM is one pillar of improved outcomes); improving quality of services (patient satisfaction is one dimension); improving quality of resource use (from stewardship of the system to cost-effectiveness of individual interventions); and improving quality of the health workplace (including compensation and supportive supervision). Development programs in CAR have experienced varying levels of success at addressing each of these components; as a result, more remains to be accomplished in some than in other. Efforts contributing to each component of quality improvement are incorporated in the HIP scope throughout USAID/CAR’s Intermediate Results.

For the purposes of this SOW, the concept of quality is interpreted broadly, following the model used by a number of authoritative bodies, such as the Institute of Medicine in its report Crossing the Quality Chasm. For clinical activities, quality can be measured in terms of compliance with written guidelines based on evidence. But the concept of quality includes the efficiency in the organization of care and in the activities that support the patient-provider interaction. The IOM concept of quality also includes patient centeredness, timelines, and safety. All of these attributes of quality will be addressed by HIP in terms of quantitative measures.

Evidence based medicine and evidence based practice are key components of improving the quality of clinical outcomes. For the purposes of this RFP, evidence based medicine is the application of evidence gained from the scientific method to certain parts of medical practice. A key component of EBM is the development of guidelines and standards using reviews of literature and analyses of scientific studies. This top-down approach can help guide national policy changes and provide tools for health providers. EBP is the practice of making decisions about health care based on the best available, current, valid and relevant evidence and often occurs at the service delivery level. This approach to making clinical determinations will be utilized by practicing health care providers. The HIP will need to work at both the national and local levels in order to integrate the two concepts.

USAID/CAR understands that many methods of collaborative quality improvement emphasize the participatory and self-led nature of the process. However, experience in Central Asia has demonstrated the necessity of outside interventions to introduce concepts included in international standards for care. Another USAID/CAR best practice is to initiate QI programs with facilities linked to medical institutes and associations to encourage broad changes in health practices throughout the health system. Experience shows that facility level quality improvement efforts should be supported at the national level. Health officials need to be involved to ensure the supportive supervision provided is consistent with the standards and indicators used by local teams.

Another critical aspect of improving quality is the need for a cultural shift within the Central Asian medical community to institutionalize effective quality improvement initiatives. This cultural transition cannot be accomplished simply through policy reform and demonstration, but requires the strategic inputs of mentoring and behavior-change communication (BCC) targeted at the full spectrum of staff within the health system, from the service provider to the sector-wide managerial and policy maker levels at the highest levels of government. BCC tools are needed to shift social and cultural influences and norms that are deleterious to health and development. The HIP will facilitate adoption of a modern quality improvement culture that includes use of innovative approaches to analyze and address not only specific clinical and managerial issues but also the broader context and environment affecting the behavior of health providers. It is expected the HIP will both contribute to and document this increased understanding of changing norms within the health profession.

5. USG and Donor Coordination

USAID partners - In all countries, the contractor will work with USAID partners implementing health activities, including those focusing on management of multi-drug resistant TB and providing outreach to risk groups for HIV and TB. Close coordination and selection of the same pilot sites are critical for the success of all of USAID’s health programs. The HIP will serve the goals of USAID’s other health projects by incorporating their policy needs into HIP’s advocacy work and technical assistance to create effective national policies, legislation, and protocols.

The contractor will also coordinate with USAID’s programs in other sectors to improve economic growth, support democratic processes and civil society. USAID is implementing projects that address education, local economic development, migration, religious tolerance, and media development, among others. The contractor is strongly encouraged to coordinate with these cross-cutting activities. Not only will this coordination provide opportunities for strong local NGOs and associations to receive additional USG support, but it will also ensure that complementary messages are provided to local government counterparts. (List of USAID activities)

World Bank - In Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan, the World Bank is implementing programs which build upon or partner with USAID initiatives in health finance reform. The contractor will work closely with the World Bank and their implementers to ensure leveraging and compatibility of programs. The HIP will serve as a technical and policy resource for Central Asian governments and World Bank implementers as they work to institute reforms to improve financing services and quality of care. The contractor will endeavor to ensure that methods to improve quality of services demonstrated under the HIP will be scaled up and incorporated into the World Bank’s programs for national reform. Country specific scopes of work listed in Section C. 4 include finance reform efforts to complement ongoing programs of the World Bank and other donors. However, as new World Bank projects begin in Tajikistan and Uzbekistan, it will be important for the contractor and USAID to provide technical support for design changes and to adjust inputs into the reform process accordingly.

Global Fund - Grants from the GFATM are implemented in four of the five countries of the region. USAID’s current program complements GFATM grants and the new program will need to plan and coordinate closely in the areas of HIV, TB, TB/HIV, infection prevention and control (IPC) and NGO capacity building. The offerer should provide a plan for coordinating efforts in the areas above.

6. Private Sector Engagement

An overall agency goal is to triple public-private partnership funding from 2007 levels by the end of 2009 through Global Development Alliances. USAID/CAR anticipates that HIP funds (particularly in the context of building civil society or educating providers and patients) will be used as leverage for private sector funding or host-government resources in two or more countries. Offerers are welcome to pursue plans for partnership with private organizations. Offerers are encouraged to define innovative, practical approaches to using these resources to promote project objectives. Offerers should not approach resource partners or request any letter of commitment until the project has been awarded. A sound strategy and approach for a development alliance with the private sector is all that is required for the proposal.

The contractor will also be expected during the course of the project to monitor and analyze the role of private sector health providers within national reforms, and include them in their quality improvement and reform efforts when appropriate.

7. Cross-border activities Central Asia faces a multitude of cross-border issues including drug trafficking, trafficking in persons, seasonal migrating populations, and the potential transmission of infectious diseases. Furthermore, the Central Asian republics are growing in importance as a result of their strategic relationship in the war against terror, as key partners in the war in Afghanistan, and as energy suppliers to the West. The U.S. Government is committed to encouraging linkages between Central and South Asia to develop corridors of trade, mutual support and coordination between governments, and services that provide maximum benefit to the people living in both regions. The contractor will seek and identify opportunities to work towards this goal, including cross-border initiatives between Tajikistan and Afghanistan, to develop solutions to common health problems.

C2. Statement of Expected Results

The HIP will be USAID/CAR’s primary activity responsible for helping to achieve the intermediate results of the Results Framework presented in Section C1(d). The HIP will conduct activities under each IR and most of the sub-IRs. The project will not carry out activities related to sub-IR 1.1 Blood Supply Improved, sub-IR 2.4 Disease Surveillance Improved or sub-IR 4.3 Outreach to Vulnerable Groups as these will be covered by other projects. Expected level of effort for each Intermediate Result is as follows:

IR1 Creating a Safer Medical Environment

25%

IR2 Strengthening Public Health Capacity

30%

IR3 Improving Quality of Health Services

30%

IR4 Empowering Civil Society to Better Respond to Health Needs 15%

Intermediate Result 1: Creating a Safer Medical Environment (LOE 25%)

IR 1.2 Infection Prevention and Control Improved

Infection prevention and control (IPC) will be a major component of the HIP. The contractor will support and improve safe medical practices by improving evidence-based policies and guidelines, strengthening surveillance, improving environmental conditions, training health-care providers, and providing supportive supervision. USAID will establish integrated, modern IPC management systems in PHC centers, central district hospitals, maternity hospitals, TB hospitals, and laboratories in both the public and where active, private sectors. IPC measures will focus on universal precautions and preventing healthcare-associated airborne and blood-borne infections.

The contractor will assist each country to develop an appropriate plan - based on international standards - to prevent healthcare-associated airborne infections in both patients and health service providers, particularly for TB. These plans will include administrative, policy, and legal changes to support IPC programmatic and environmental interventions in PHC facilities and in the penitentiary system. All national plan recommendations will be piloted in specific sites in each country and incorporated into quality improvement programs. These activities will be closely coordinated with USAID’s multi-drug-resistant TB case management and social support activity. All three types of infection control measures (administrative, environmental and personal respiratory protection) will be conducted in pilot facilities.

The contractor will assist each country to develop a plan for the prevention of healthcare-associated transmission of blood-borne diseases. The contractor should increase capacities of the Ministries of Health to implement IPC in healthcare facilities. The plans should include revision of the IPC guidelines to include relevant information (based on WHO guidelines) on safe injection and safe blood drawing, and for safe management of healthcare waste. The guidelines should include information on the rational use of injection medications and transfusion of blood and blood products. Training on universal precautions should be included into the plan.

The contractor will build the capacity of national Sanitary and Epidemiological Services (SESs), National AIDS and TB Centers, GFATM Principal Implementation Units (PIUs) and other relevant actors within the Ministries of Health (varying by country), and penitentiary systems to implement IPC quality assurance measures at the national and facility levels. In some countries, the role of national SESs will be supported as a unit responsible for training and monitoring infection control activities, as opposed to its existing, primarily disciplinary role. In countries where another organization is already fulfilling this role, the contractor will provide support to update and train providers on national IPC guidelines. Implementation of IPC standards at the facility level will include introduction of universal precautions to control various types of infections. Implementation of standards will also include specific policies for decontamination and sterilization activities as well as establishment of multidisciplinary teams who will address infection problems. SES will be encouraged to provide strong administrative support and supportive supervision. Quality improvements will rely on defining process failures, while integrating traditional IPC components. Additional technical support and training will be provided to improve health worker safety (e.g. Hepatitis vaccination and Post-Exposure Prophylaxis (PEP) policies). The contractor will build the capacity of managers to forecast equipment needs (e.g. single-use syringes, catheters, and IVs) and procure accordingly. Support will be provided to develop policies for safe healthcare waste management systems, which will be demonstrated in pilot sites.

As described in the Overall Strategy section C1.(e), the transition within the medical profession from a culture of inspection to supportive supervision is essential for improving infection control practices and for implementing truly collaborative quality improvement programs. The contractor will also assist appropriate MOH departments to develop messages, materials, job aids and counseling materials to address unnecessary demand for injection and transfusion. These tools will be utilized in quality improvement pilot sites. Behavior change at the community level is another critical component for the contractor to address. The contractor will work with communities to develop materials, launch education campaigns, and change behaviors on issues such as blood donation, expecting injections or blood transfusions as a standard course of treatment and other potentially dangerous practices.

Intermediate Result 2: Building Public Health Capacity (LOE 30%)

IR 2.1

Methods for Improving Quality of Care Institutionalized

This sub-IR is a cross-cutting theme. Please see IR 3.1 for a complete description.

IR 2.2

Management Improved

The HIP will be a critical source of management technical assistance and support for MOHs, TB and AIDS centers, SESs, laboratories, medical institutes, community organizations, and other organizations. The contractor will provide assistance to these entities to help strengthen their capacity to improve the quality, scope and coordination of health services. The contractor will also support national health programs to implement reforms to help improve the efficiency and effectiveness of the health system.

The HIP will build upon the successes of ZdravPlus II in health finance reform by working to institutionalize existing reforms in some countries, and scaling them up in others (e.g. moving from rural to urban centers for primary health-care finance reform, or from the primary health-care level to the hospital level in countries where financing for hospital care has not yet been reformed). The contractor will be expected to utilize the tools developed by USAID’s health reform projects to assist governments and civil society to find ways to increase funding for health.