Final RFP_HE176-09-005.DOC

OPENING DATE:

Thursday, March 19, 2009

CLOSING DATE:

Monday, May 4, 2009

CLOSING TIME:

5:00 pm, Almaty Time (or 7:00 am Eastern time)

SUBJECT:

Request for Proposal (RFP) No. HE176-09-005, 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 seeking proposals to provide the services described in the attached Request for Proposals. The purpose of the activity is to procure technical assistance, training, equipment and commodities to assist the Central Asian republics 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, HIV/AIDS, maternal and child health, and primary health care.

You are invited to submit a proposal in accordance with the requirements of the RFP. This procurement shall be conducted through full and open competition, under which any type of organization is eligible to compete. The procedures set forth in FAR Part 15 shall apply.

Please consider the following information: There are not any registration concerns with the countries of Kazakhstan and Kyrgyzstan. However, the laws and decrees in Uzbekistan and Tajikistan require that foreign legal entities must be registered to do business within those countries. These procedures are quite lengthy and it may take up to a year or longer before an organization knows whether its registration is accepted by the host governments. In Turkmenistan, implementing partners who do not have an existing relationship with the government have not been able to effectively function, though registration of foreign NGO branch offices is not a legal requirement. Given the in-country operating environments for Uzbekistan, Tajikistan and Turkmenistan in relation to registration and presence, the offeror through itself, or subcontractors, or joint-venture members must demonstrate current registration in Tajikistan and Uzbekistan and an established presence in Turkmenistan. Information on non-governmental organizations (NGOs) operating in such countries can be found through various English and Russian-language websites and NGO organizations. We also encourage organizations which are registered in Tajikistan or Uzbekistan or have an established presence in Turkmenistan to express their status as such on the “Interested Vendor List” at www.fbo.gov to assist in making this information known to others.

If you decide to submit a proposal, it must be presented in accordance with the attached solicitation and received no later than 5:00 pm, local Almaty, Kazakhstan, time on the Closing Date indicated above at the place shown below. Proposals and modifications thereof, should be submitted with the name, street address, telephone number, internet email address of a point-of-contact who is an authorized agent of the offeror and Request for Proposal Number inscribed thereon, must be addressed to:

John Griffin

Contracting Officer

USAID/CAR

Internet email for electronic submission: Internet email: AlmatyAAsolicitations@usaid.gov Facsimile: +7 (3272) 50-76-35 or 36

U.S. based mailing address:

USAID/DOS

7030 Almaty Place

Washington, DC 20521-7030

Street/delivery address:

USAID/CAR, Acquisition and Assistance Office

41 Kazibek bi Street

Park Palace Building

Almaty, Kazakhstan 050000

Tel 7-3272-50-48-02

This RFP in no way obligates USAID to award a contract nor does it commit USAID to pay any cost incurred in the preparation and submission of a proposal. Notifications of receipt and questions concerning this RFP must be directed to the Contracting Officer via either the internet email address or facsimile numbers listed above.

Sincerely, John Griffin

Regional Contracting Officer

Table of Contents Page

7PART I - THE SCHEDULE

7SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

7B.1 PURPOSE

7B.2 CONTRACT TYPE

7B.3 ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT

7B.4 PRICE SCHEDULE

7B.5 INDIRECT COSTS (DEC 1997)

8B.6 CEILING ON INDIRECT COST RATES (DEC 1997)

8B.7 COST REIMBURSABLE

9SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

46SECTION D – BRANDING AND MARKING

46D.1 752.7009 MARKING (Jan 1993)

46D.2 BRANDING AND MARKING POLICY

46D.3 BRANDING STRATEGY

47D.4 BRANDING IMPLEMENTATION PLAN AND MARKING PLAN

48SECTION E - INSPECTION AND ACCEPTANCE

48E.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

48E.2 INSPECTION AND ACCEPTANCE

49SECTION F - DELIVERIES OR PERFORMANCE

49F.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

49F.2 PERIOD OF PERFORMANCE

49F.3 PERFORMANCE STANDARDS

49F.4 REPORTS AND DELIVERABLES OR OUTPUTS

50F.5 752.242-70 PERIODIC PROGRESS REPORTS (July 1998)

51F.6 752.7005 SUBMISSION REQUIREMENTS FOR DEVELOPMENT EXPERIENCE DOCUMENTS (JAN 2004)

51F.7 KEY PERSONNEL

53SECTION G - CONTRACT ADMINISTRATION DATA

53G.1 AIDAR 752.7003 DOCUMENTATION FOR PAYMENT (NOV 1998)

54G.2 ADMINISTRATIVE CONTRACTING OFFICE

54G.3 CONTRACT OFFICER’S TECHNICAL REPRESENTATIVE (COTR)

54G.4 TECHNICAL DIRECTIONS/RELATIONSHIP WITH USAID

56G.5 PAYING OFFICE

56G.6 ACCOUNTING AND APPROPRIATION DATA

57SECTION H - SPECIAL CONTRACT REQUIREMENTS

57H.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

57H.2 WORKER’S COMPENSATION INSURANCE (DEFENSE BASE ACT).

57H.3 AIDAR 752.7004 EMERGENCY LOCATOR INFORMATION (JUL 1997)

57H.4

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

58H.5 AUTHORIZED GEOGRAPHIC CODE

58H.6 NONEXPENDABLE PROPERTY PURCHASES AND INFORMATION TECHNOLOGY RESOURCES

58H.7 LOGISTIC SUPPORT

58H.8 LANGUAGE REQUIREMENTS

58H.9 SUBCONTRACTING PLAN AND THE SF 294 - SUBCONTRACTING REPORT FOR INDIVIDUAL CONTRACTS AND SF 295 - SUMMARY CONTRACTING REPORT

58H.10 EXECUTIVE ORDER ON TERRORISM FINANCING (FEB 2002)

59H.11 REPORTING OF FOREIGN TAXES

59H.12 USAID DISABILITY POLICY - ACQUISITION (DECEMBER 2004)

60H.13 AIDAR 752.225-70 SOURCE, ORIGIN AND NATIONALITY REQUIREMENTS (FEB 1997)

61H.14 GRANTS UNDER CONTRACTS

61H.15 752.7007 PERSONNEL COMPENSATION (JUL 2007)

62SECTION I - CONTRACT CLAUSES

62I.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

64I.2 52.204-7 CENTRAL CONTRACTOR REGISTRATION (JUL 2006)

65I.3 52.203-13 CONTRACTOR CODE OF BUSINESS ETHICS AND CONDUCT (DEC 2008)

67I.4 52.222-50 COMBATING TRAFFICKING IN PERSONS (FEB 2009)

68I.5 52.225-19 CONTRACTOR PERSONNEL IN A DESIGNATED OPERATIONAL AREA OR SUPPORTING A DIPLOMATIC OR CONSULAR MISSION OUTSIDE THE UNITED STATES (MAR 2008)

71I.6 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

72I.7 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000)

72I.8 52.222-39 NOTIFICATION OF EMPLOYEE RIGHTS CONCERNING PAYMENT OF UNION DUES OR FEES (DEC 2004)

73I.9 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

74I.10 AIDAR 752.7032 INTERNATIONAL TRAVEL APPROVAL AND NOTIFICATION REQUIREMENTS (JAN 1990)

74I.11 752.7101 VOLUNTARY POPULATION PLANNING ACTIVITIES (JUNE 2008)

75I.12 ORGANIZATIONS ELIGIBLE FOR ASSISTANCE (ACQUISITION) (JUNE 2005)

76I.13 CONDOMS (ACQUISITION) (JUNE 2005)

76I.14 PROHIBITION ON THE PROMOTION OR ADVOCACY OF THE LEGALIZATION OR PRACTICE OF PROSTITUTION OR SEX TRAFFICKING (ACQUISITION) (JUNE 2005)

77SECTION J - LIST OF ATTACHMENTS

79SECTION K - REPRESENTATIONS, CERTIFICATIONS AND

OTHER STATEMENTS OF OFFERORS

79K.2 52.204-8 ANNUAL REPRESENTATIONS AND CERTIFICATIONS (JAN 2006)

80K.3 INSURANCE - IMMUNITY FROM TORT LIABILITY

80K.4 52.230-1 COST ACCOUNTING STANDARDS NOTICES AND CERTIFICATION (JUNE 2000)

82K.5 52.230-7 PROPOSAL DISCLOSURE—COST ACCOUNTING PRACTICE CHANGES (APR 2005)

82K.6 SIGNATURE

83SECTION L - INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS

83L.1 52.215-1 INSTRUCTIONS TO OFFERORS – COMPETITIVE ACQUISITION (JAN 2004)

86L.2 52.216-1 TYPE OF CONTRACT (APR 1984)

87L.3 52.233-2 SERVICE OF PROTEST (SEP 2006)

87L.4 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998)

87L.5 GENERAL INSTRUCTIONS TO OFFERORS

88L.6 INSTRUCTIONS FOR THE PREPARATION OF THE TECHNICAL PROPOSAL

91L.7 INSTRUCTIONS FOR THE PREPARATION OF THE COST PROPOSAL

94L.9 PARTICIPANT TRAINING

95SECTION M - EVALUATION FACTORS FOR AWARD

95M.1 EVALUATION CRITERIA

98M.2 DETERMINATION OF THE COMPETITVE RANGE AND CONTRACT AWARD

98M.3 CONTRACTING WITH SMALL BUSINESS CONCERNS AND DISADVANTAGED ENTERPRISES

99ATTACHMENTS

99ATTACHMENT 1 IDENTIFICATION OF PRINCIPAL GEOGRAPHIC CODE NUMBERS

100ATTACHMENT 2 USAID FORM 1420-17 - CONTRACTOR BIOGRAPHICAL DATA SHEET

103ATTACHMENT 3 SF LLL - DISCLOSURE OF LOBBYING ACTIVITIES

107ATTACHMENT 4 CONTRACTOR PERFORMANCE REPORT SHORT FORM

108ATTACHMENT 5 SAMPLE SMALL BUSINESS SUBCONTRACTING PLAN

112ATTACHMENT 6 ENVIRONMENTAL COMPLIANCE REQUIREMENTS FOR HIP

114ATTACHMENT 7 PARTICIPANT TRAINING REPORT

117ATTACHMENT 8 - USAID/CAR Results Framework for Health (available as a separate document)

117ATTACHMENT 9 Analysis of status of Infection Prevention and Control (IPC) measures in hospitals in Kyrgyzstan (available as a separate document)

117ATTACHMENT 10 WHO Policy on TB Infection Control (available April 2009) (available as a separate document)

117ATTACHMENT 11 ZdravPlusII Mid-Term Evaluation Report (available as a separate document)

117ATTACHMENT 12 USAID supported activities and contact information (available as a separate document)

117ATTACHMENT 13 Table of Global Fund grants (available as a separate document)

117ATTACHMENT 14 Country strategies (multiple documents) (available as a separate document)

117ATTACHMENT 15 ENVIRONMENTAL COMPLIANCE FACESHEET FOR THE INITIAL ENVIRONMENTAL EXAMINATION (IEE) (available as a separate document)

117ATTACHMENT 16 Conceptual Paper: A Health Systems Approach to TB Control in Central Asia

117(available as a separate document)

117ATTACHMENT 17 List of Continuous Quality Improvement (CQI) sites (available as a separate document)

118ATTACHMENT 18 Additional Website Links

119ATTACHMENT 19 Template Marking and Implementation Plans

128ATTACHMENT 20 Questions and Answers in regards to the RFP

134ATTACHMENT 21 List of Parties Expressed interest in the RFP

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 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, HIV/AIDS, maternal and child health, and primary health care.

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. Grants

c. Fixed Fee

d. Total Cost + Fixed Fee

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

Acronym List

C.1. BACKGROUND

(a) Overview

The goal of this contract is to improve the health status of Central Asians by building the capacity of 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 maternal and child health (MCH) services at primary and secondary levels of care, and, as appropriate, support the continued development of primary health care (PHC) as defined by the World Health Organization (WHO). 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 ten 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 (STI), 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 pay for 76% of healthcare costs.

Maternal mortality is the single greatest cause of female adult mortality throughout CAR. 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.

A TB epidemic compounded by the growing threat of multi-drug-resistant tuberculosis (MDR TB) casts a long shadow over the region’s future. TB presents a major challenge to the region’s health-care systems, and to economic development via decreased workforce productivity. According to WHO, four of the five Central Asian countries exhibit some of the highest recorded rates of MDR TB in the world (there is no data for Turkmenistan). Deviation from international treatment standards, interruptions in drug supply, poor patient compliance with treatment, and poor infection control in civil sector TB and prison health facilities have all contributed to this serious problem.

Of the five countries, Tajikistan suffers the highest TB incidence and mortality rates, with 204 cases per 100,000 persons, and 39 deaths per 100,000 persons. Although there have been impressive gains in TB control and prevention, much remains to be done to mitigate the further spread of this serious infectious disease. Case detection has steadily improved under DOTS in all countries except Kazakhstan, but none have reached the WHO target of 70 percent. Turkmenistan, Kyrgyzstan, and Tajikistan have officially reached the 85 percent target for TB treatment success rate, though Turkmenistan slipped slightly from 86 percent in 2005 to 81 percent in 2006. Over the past four years, the TB treatment success rate in Uzbekistan has hovered around 80 percent, while Kazakhstan has seen declines in TB treatment success and case detection rates since 2002. Kazakhstan has the highest treatment failure rate (12 percent), while Uzbekistan exhibits the highest default-from-treatment rate, especially among retreatment cases (20 percent).

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. 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 use of improperly sterilized 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 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.

Systemic structures and cultural issues within the medical community prevent CAR governments from being responsive to the health needs of their populations. Health sectors are unable to adjust to meet changing needs or modernize protocols due to rigid and unwieldy bureaucracies. Clinical practice is often determined by tradition, as opposed to scientific evidence; the process of producing guidelines for treatment and diagnosis can be based upon the subjective opinion of a few experts, as opposed to medical evidence. Management and supervision techniques are commonly limited to inspection and punishment, as opposed to guidance and mentoring. The idea of the patient as a participant in health and health care is also new to the region. Because of low salaries and status, CAR have lost and continue to lose medical practitioners through emigration, particularly to Russia. This phenomenon, combined with the unwillingness of students to enter into careers in family medicine, TB medicine, or laboratory work, has created a human resource emergency in CAR, especially in Kyrgyzstan and Tajikistan.

(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. 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 budgets to provide more support for primary health care and 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 (EBM) 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. In its second and third contract periods, Zdrav implemented quality improvement programs to demonstrate best practices for specific medical interventions. (http://www.zplus.kz) 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 January 2008 and operating through September 2009, 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 (MOH) to expand MDR TB case management services throughout Almaty and East Kazakhstan oblasts. It will 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 MOH 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 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 Global Fund to Fight AIDS, Tuberculosis and Malaria (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. 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. Voluntary counseling and testing models for drug users and sex workers are being tested in Kyrgyzstan and Kazakhstan. Condom social marketing activities targeting MARPs and at-risk youth were supported in four Central Asian Republics. CAPACITY also provided organizational development assistance to a number of AIDS servicing organizations that provide comprehensive package of HIV prevention services to MARPs. (http://www.capacityproject.info) The Drug Demand Reduction Program (DDRP) 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.

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 five years with health messages.

USAID’s Health Partnership Program provided assistance in building health management capacity, establishing community-oriented primary care, improving undergraduate education, and prevention of vertical transmission of HIV. The program improved the capacity of health professionals to access and use information and communication technology and evidence-based medical resources to expand their knowledge and improve the quality of patient care.

With the design of the HIP, USAID seeks to build upon the success of past reform projects, by combining system reform work to serve vulnerable groups with specific interventions in the areas of HIV/AIDS, TB, MCH and PHC. The past strategy of promoting EBM overall while demonstrating examples of excellence will be expanded and adjusted, so that EBM, evidence based practices and the principles of quality improvement themselves become institutionalized.

(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 in four CAR.

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 Round 7 of the Global Fund will implement programs that were developed by USAID’s DDR program in other CAR. Grants for TB will help expand prevention and treatment of TB 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 the Swiss Agency for Development and Cooperation, The Swedish International Development Agency, the European Union, the Japanese International Cooperation Agency, the Turkish International Cooperation Agency, and the British Department for International Development (DfID). DfID and the German Development Bank (KfW) 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 to 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 on health status. 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 emphasis. The HIP’s greatest inputs will be in Tajikistan (29%), followed by Kyrgyzstan (25%), Uzbekistan (19%), 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.)

It is expected that funding, and corresponding program activities, for the entire regional program will be divided between the five elements in similar proportions to those included in the table below. However, proportions will vary in each country over each year of implementation.

Planned funding for HIP by program element and country

While activities in these five program elements will be implemented under the HIP, they will contribute towards achieving the four Intermediate Results listed in the results framework and described in Section C.2.

The HIP 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. Strengthening PHC

USAID/CAR has worked to strengthen PHC for fifteen years, and is committed to solidifying the gains made by this investment. Through the HIP, USAID will support improvements to the implementation of PHC as defined by WHO.

For the purposes of this RFP, “primary care” will be used to indicate a level of health facility or provider, while “PHC” will indicate a package of essential services, as defined by WHO.

HIP was designed to incorporate aspects of traditionally vertical programs (HIV and TB interventions) with an overall systems strengthening approach that prioritizes capacity at the primary care level. In this way, it is expected that the capacity of horizontal health structures will be developed, not detracted from, through the integration of what are now considered to be vertical programs. The contractor will work, through every aspect of the HIP, to build upon the gains made in strengthening PHC in some CAR, and assist other CAR to learn from their neighbors’ experiences to make similar reforms.

4. Bottom-Up, Top-Down Approach

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 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 purpose of this program is not to implement pilot programs with limited scope. Many successful pilots have already been demonstrated in CAR, and there is a need for a coordinated effort to act on previously established best practices for the region. An important goal of the HIP will be to assist 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.

5. 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 HIP will support CAR health systems to adapt modern quality improvement (QI) approaches to their needs and priorities. The project will seek to directly improve health care processes in order to improve health outcomes. Much of this work is expected to focus on Congressionally-mandated health priorities, but also to contribute to a broader strengthening of health systems. The program should take a top to bottom approach for QI that includes improving the quality of care, resulting in improved 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 countries than in others. Efforts contributing to each component of QI are incorporated in the HIP scope throughout USAID/CAR’s Intermediate Results.

For the purposes of this RFP, 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.

EBM and evidence based practices are key components of improving the quality of clinical outcomes. One lesson learned from USAID’s work on health reform is that EBM is not simply the development of guidelines and standards using reviews of literature and analyses of scientific studies, although this approach can help guide national policy and provide tools for health providers. EBM is also the practice of making decisions about health care at the service delivery level, based on the best available, current, valid and relevant evidence, clinical experience, and ultimately, the patient’s values and wishes. The HIP will need to work at both the national and local levels in order to ensure that this approach to making clinical determinations will be utilized by practicing health care providers.

USAID/CAR understands that many methods of collaborative QI 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 QI 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. HIP will also support counterparts in developing systems for monitoring clinical quality, and will provide support for spreading documented improvements through the health system. Offerers are encouraged to describe a defined approach for extending improved practices to provincial or national scale. This approach should take into account current knowledge of the planned spread of innovations and the capacity of CAR health systems to support such a strategy.

Another critical aspect of improving quality is the need for a cultural shift within the Central Asian medical community to institutionalize effective QI 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 managers and policy makers 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 QI 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.

6. USG and Donor Coordination

USAID programs - In all countries, the contractor will work with USAID implementers, including those focusing on management of MDR TB and providing outreach to risk groups for HIV and TB.