IHI NOFO No. 72030625RFA00001 AMENDMENT No. 1.pdf

December 24, 2024

Subject: Amendment 01

Reference: Notice of Funding Opportunity Number NOFO No. 72030625RFA00001;

Integrated Health Initiative (IHI) Activity

Dear Interested Applicants:

The purpose of Amendment No. 01 to the NOFO No. 72030625RFA00001 is to:

1. To Amend the NOFO. All changes from the original version are highlighted in yellow.

Please carefully review the revised NOFO.

2. Provide responses to the questions received during the questions-answers period, as specified in Annex 1 to this Amendment.

All other information in the original NOFO remains unchanged and in full effect.

Thank you for your interest in USAID programs.

Sincerely, /s/

Claudio Ballesteros

Agreement Officer

USAID/Afghanistan

Annex 1: 72030625RFA00001_Q&A

Issue Date: December 24, 2024

Deadline for Questions: December 20, 2024, at 07:00 U.S. Eastern Standard Time (EST)

Closing Date and Time: January 24, 2025

Closing Time: 07:00 U.S. Eastern Standard Time (EST)

Subject: Notice of Funding Opportunity Number (NOFO): 72030625RFA00001

Program Title: Integrated Health Initiative (IHI) Activity

Federal Assistance Listing Number: 98.001-- USAID Foreign Assistance for Programs Overseas

To All Prospective Applicants, The United States Agency for International Development (USAID) is seeking applications for a

Cooperative Agreement from qualified entities to implement the Integrated Health Initiative (IHI)

Activity. Eligibility for this award is not restricted.

USAID intends to make an award to the applicant(s) who best meets the objectives of this funding opportunity based on the merit review criteria described in this NOFO, subject to a risk assessment.

Eligible parties interested in submitting an application are encouraged to read this NOFO thoroughly to understand the type of program sought, application submission requirements, and selection process.

To be eligible for award, the applicant must provide all information as required in this NOFO and meet eligibility standards in Section B of this NOFO. This funding opportunity is posted on www.grants.gov and may be amended. It is the responsibility of the applicant to regularly check the website to ensure they have the latest information pertaining to this NOFO and to ensure that it has been downloaded from the internet in its entirety. USAID bears no responsibility for data errors resulting from transmission or conversion process. If you have difficulty registering on www.grants.gov or accessing the NOFO, please contact the Grants.gov Support Center at 1-800-

518-4726 or via email at support@grants.gov for technical assistance or if you need assistive technology and are unable to access any material on this site.

Unless an exception in 2 CFR 25.110 applies, applicants must comply with 2 CFR 25 requirements to obtain a Unique Entity Identifier (UEI) and register in the System for Award Management

(SAM.gov), as applicable. See Section E, Submission Requirements and Deadlines, for more information. The registration process may take many weeks to complete. Therefore, applicants are encouraged to begin registration early.

Please send any questions to the point(s) of contact identified in Section A.4. The deadline for questions is shown above. Responses to questions received prior to the deadline will be furnished to all potential applicants through an amendment to this notice posted to www.grants.gov.

http://www.grants.gov/ mailto:support@grants.gov

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

Issuance of this NOFO does not constitute an award commitment on the part of the Government nor does it commit the Government to pay for any costs incurred in preparation or submission of comments/suggestions or an application. Applications are submitted at the risk of the applicant. All preparation and submission costs are at the applicant’s expense.

Thank you for your interest in USAID programs.

Sincerely, /s/

USAID/Afghanistan

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

NOFO TABLE OF CONTENTS

Section - A Basic Information 4

Section - B Eligibility 6

Section - C Program Description 7

Section - D Application Content and Format 24

Section - E Submission Requirements and Deadlines 37

Section - F Application Review Information 39

Section - G Award Notices 43

Section - H Post-Award Requirements and Administration 44

Section - I Other Information 50

Annexes and Attachments 51

Annex - 1 Summary Budget Template 51

Annex - 2 Standard Provisions 52

Annex - 3 Abbreviations and Acronyms 62

List of Attachments 64

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

SECTION A: BASIC INFORMATION

1. Executive Summary

The Integrated Health Initiative (IHI) Activity (Activity) will increase equitable access to and use of quality health services, and increase adoption of healthy behaviors, especially for women and children, in USAID target areas in Afghanistan. The Activity’s priority health areas are maternal and newborn health (MNH); family planning and reproductive health (FP/RH); child health;

nutrition; tuberculosis (TB); and mental health. This Activity will build on prior USAID investments, particularly the Assistance to Families and Indigent Afghans to Thrive (AFIAT), the

Urban Health Initiative (UHI), and the Local Health System Sustainability (LHSS) activities.

The IHI Activity will focus on five high-density population provinces - Kabul, Kandahar, Nangarhar, Herat, and Balkh - with a total population of 12.2 million, which is approximately 25 percent of the total population of the country. These five provinces have a high disease burden, vulnerable populations, and limited access to health services due to distance, high costs, low awareness, and a shortage of female health care providers. Additionally, Kandahar, Herat and

Nangarhar have recently received large numbers of Afghans returning from neighboring countries.

These populations settle in urban areas for long periods of time before they go to their native provinces, resulting in increased stress to health and other social services.

Within these provinces, the Activity will focus on the most vulnerable populations, particularly women, children and marginalized groups. Health workers at all levels also constitute an important beneficiary population due to their central role in providing quality and respectful health services.

The Activity will engage men because of the critical role they play in family decision-making related to health.

The IHI Activity will need to support a range of different health facilities such as specialty, regional and district hospitals; comprehensive and basic health centers; health posts; and private health facilities. Supporting the private sector is critical to improving access to and the quality of services in the five priority provinces of this Activity. Private facilities already serve a large proportion of the target population; offer opportunities to increase demand for commodities and services through social marketing programs; and some private for-profit entities provide subsidized schemes for poor and needy populations to make health services more affordable.

2. Estimate of Funds Available and Number of Awards Contemplated

USAID intends to award One (1) Cooperative Agreement pursuant to this Notice of Funding

Opportunity (NOFO).

Subject to funding availability and at the discretion of the Agency, USAID intends to provide

$92,500,000.00 in total USAID funding over a five (5) year’s period.

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

3. Start Date and Period of Performance for Federal Awards

The anticipated period of performance is five (5) years. The estimated start date is on/before May

01, 2025.

4. Agency Point of Contact

Email: cballesteros@usaid.gov

Ahmad Jawid Mashal

Senior Acquisition & Assistance Specialist

Email: ahjawid@usaid.gov

5. Acquisition and Assistance Ombudsman

The A&A Ombudsman helps ensure equitable treatment of all parties who participate in USAID’s acquisition and assistance process. The A&A Ombudsman serves as a resource for all organizations who are doing or wish to do business with USAID. Please visit this page for additional information:

https://www.usaid.gov/work-usaid/acquisition-assistance-ombudsman.

The A&A Ombudsman may be contacted via: Ombudsman@usaid.gov

6. Authorized Geographic Code

The geographic code for the procurement of commodities and services under this program is 935.

Except as may be specifically approved in advance by the Agreement Officer, all commodities and services that will be reimbursed by USAID under this award must be from the authorized geographic code specified in this NOFO and must meet the source and nationality requirements set forth in 22 CFR 228.

----End of Section A – Basic Information-----mailto:cballesteros@usaid.gov mailto:ahjawid@usaid.gov https://www.usaid.gov/work-usaid/acquisition-assistance-ombudsman https://www.usaid.gov/work-usaid/acquisition-assistance-ombudsman

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

SECTION B: ELIGIBILITY

1. Eligible Applicants

Eligibility for this NOFO is not restricted. All qualified U.S. and non-U.S. organizations (other than those from foreign policy restricted countries) are eligible to apply. Pursuant to Code of Federal

Regulations (CFR) 200.400(g), it is USAID policy not to award profit under assistance instruments such as Cooperative Agreements, and as such, for-profit organizations must waive profits and/or fees to be eligible to submit an application. Forgone profit does not qualify as cost share or leverage.

Faith-based organizations are eligible to apply for federal financial assistance on the same basis as any other organization and are subject to the protections and requirements of Federal law.

Applicants must have established financial management, monitoring and evaluation processes, internal control systems, and policies and procedures that comply with established U.S.

Government standards, laws, and regulations.

The Recipient must be a responsible entity. The AO may determine a pre-award survey is required to conduct an examination that will determine whether the prospective recipient has the necessary organization, experience, accounting and operational controls, and technical skills – or ability to obtain them – in order to achieve the objectives of the program and comply with the terms and conditions of the award.

Faith-based organizations are eligible to apply for federal financial assistance on the same basis as any other organization and are subject to the protections and requirements of Federal law.

Additionally, USAID welcomes applications from organizations that have not previously received financial assistance from USAID.

2. Cost Sharing

USAID has established a required minimum recipient cost share of five (5) percent for the award.

Such funds may be provided directly by the recipient; other multilateral, bilateral, and foundation donors; host governments; and local organizations, communities and private businesses that contribute financially and in-kind to implementation of activities at the country level. This may include contribution of staff level of effort, office space or other facilities or equipment which may be used for the program, provided by the recipient. For guidance on cost sharing in federal financial assistance see 2 CFR 200.306. Applicants may refer to Section D, Application Content and Format, regarding requirements for the submission of letters or other documentation to verify commitments to meet cost-sharing requirements.

----End of Section B – Eligibility-----

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

SECTION C: PROGRAM DESCRIPTION

This funding opportunity is authorized under the Foreign Assistance Act (FAA) of 1961, as amended. The resulting award will be subject to 2 CFR 200 – Uniform Administrative

Requirements, Cost Principles, and Audit Requirements for Federal Awards, and USAID’s supplement, 2 CFR 700, as well as the additional requirements found in Section H.

1. Introduction

The Integrated Health Initiative (IHI) Activity (Activity) will increase equitable access to and quality of health services and increase adoption of healthy behaviors, especially for women and children, in USAID target areas in Afghanistan. The Activity’s priority health areas are maternal and newborn health (MNH); family planning and reproductive health (FP/RH); child health;

nutrition; tuberculosis (TB); and mental health. This Activity will build on prior USAID investments, particularly the Assistance to Families and Indigent Afghans to Thrive (AFIAT), the

Urban Health Initiative (UHI), and the Local Health System Sustainability (LHSS) activities.

The IHI Activity will focus on five high-density population provinces - Kabul, Kandahar, Nangarhar, Herat, and Balkh - with a total population of 12.2 million, which is approximately 25 percent of the total population of the country. These five provinces have a high disease burden, vulnerable populations, and limited access to health services due to distance, high costs, low awareness, and a shortage of female health care providers. Additionally, Kandahar, Herat and

Nangarhar have recently received large numbers of Afghans returning from neighboring countries.

These populations settle in urban areas for long periods of time before they go to their native provinces, resulting in increased stress to health and other social services.

Within these provinces, the Activity will focus on the most vulnerable populations, particularly women, children and marginalized groups. Health workers at all levels also constitute an important beneficiary population due to their central role in providing quality and respectful health services.

The Activity will engage men because of the critical role they play in family decision-making related to health.

The IHI Activity will need to support a range of different health facilities such as speciality, regional and district hospitals; comprehensive and basic health centers; health posts; and private health facilities. Supporting the private sector is critical to improving access to and the quality of services in the five priority provinces of this Activity. Private facilities already serve a large proportion of the target population; offer opportunities to increase demand for commodities and services through social marketing programs; and some private for profit entities provide subsidized schemes for poor and needy populations to make health services more affordable.

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

2. Background and Context

a) Country Context

The Taliban takeover of Afghanistan on August 15, 2021, led to broad economic and political instability and disruption of basic service provision, requiring donors to step in to prevent the collapse of basic health care and education services. In addition, years of conflict, the COVID-19 pandemic, internal displacement, returnees from Pakistan and other countries, and several natural disasters placed added stress on Afghanistan. The United Nations ranks Afghanistan as one of the most vulnerable countries to the impact of climate change. The number of droughts has doubled compared to previous decades and heavy rainfall events have increased, accompanied by flash floods and landslides.

Twenty-nine million Afghans require humanitarian assistance to meet basic water, sanitation, health, and hygiene needs. It is estimated that 47 percent of Afghan children under five years of age are stunted, while 35 percent of the population is projected to experience crisis or emergency levels of food insecurity and limited livelihood opportunities (Multiple Indicator Cluster Survey (MICS), 2023). Women, displaced people, and other marginalized populations are particularly affected.

According to the United Nations Development Program (UNDP) 2023 Afghanistan Socio-

Economic Outlook report, the number of poor people increased to 34 million in 2022 from 19 million in 2020, accounting for approximately 85 percent of the population. Many businesses have been forced to close, and many Afghans have been left without a sustainable source of income. This has had an enormous impact on the economy and disproportionately affects women and youth.

Young people, who constitute approximately 67 percent of the population, face significant challenges related to health, education, and employment.

b) Health Context

Between 2001 and 2021, Afghanistan made remarkable gains in health status – significantly reducing maternal mortality from 1,600 deaths per 100,000 live births in 2000 to 620 in 2020 (UN

Maternal Mortality Estimate, 2020) and decreasing under-five mortality from 97 per 1,000 live births in 2010 to 56 in 2021 (UN Child Mortality Estimate, 2021). The TB treatment success rate improved from less than 50 percent in 2000 to 93 percent in 2023 (WHO Global Tuberculosis

Report, 2023); and the number of functioning public health facilities grew from 496 in 2002 to more than 3,000 in 2023 (Afghanistan Health Management Information System (HMIS), 2023).

Despite this progress, Afghanistan faces critical health problems, especially for women and children. While maternal mortality has fallen significantly, it is still among the highest in the world.

The leading causes of death among women are obstetric hemorrhage (27 percent), infections (22 percent), and abortion (7 percent) (Afghanistan Health Survey (AHS), 2018). Only 33.4 percent of pregnant women attend all four recommended antenatal visits. The proportion of deliveries taking place at a health facility is 66.3 percent, while those who deliver with skilled birth attendance is 67.5 percent. Almost one-third of childbirths (33.4 percent) still take place at home without skilled attendance. The proportion of mothers who attend postnatal care (PNC) visits within two days after childbirth remains low at 36.3 percent (MICS, 2023).

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

Afghanistan’s contraceptive prevalence rate remains one of the lowest in the world, with 17.4 percent of married women using a modern method (AHS, 2018), contributing to a high fertility rate of 5.4 (MICS, 2023). Globally, Afghanistan has one of the highest rates of unmet need for family planning at 26.8 percent (FP Track20, 2023). The FP method discontinuation rate is also high, with 26 percent of users discontinuing within 12 months of starting to use a method (DHS, 2015).

Children in Afghanistan are also at risk for numerous poor health outcomes. The newborn mortality rate is 34 deaths per 1,000 live births (UN Child Mortality Estimate, 2021), and follow-up visits for newborns within two days is only 34.2 percent (MICS, 2023). The leading causes of death in children under-five are sepsis/meningitis (19.9 percent), preterm birth complications (19.8 percent), and pneumonia (17.2 percent). Infections accounted for over 62.8 percent of all deaths among children under five years old (AHS, 2018). Childhood illness is exacerbated by very low vaccination coverage - only 36.6 percent of children 12-23 months old have received all basic immunizations (MICS, 2023), and the number of acute malnutrition cases is increasing (UNICEF

Nutrition Report, 2023).

Additionally, tuberculosis is a growing problem and in 2020 was the third leading cause of mortality in Afghanistan among communicable, maternal, neonatal and nutritional diseases, with

24 deaths per 100,000 population (Stop TB dashboard data). In 2023, only 65 percent of cases were detected by the National Tuberculosis Program, suggesting that a large number of TB cases

(around 35 percent) are not identified by routine health services. (WHO Global TB Report, 2023).

The notification rate for drug-resistant TB (DR-TB) remains low, with only 658 out of an estimated

1,700 cases (39 percent) reported in 2023. TB case notification among children is relatively high at 22 percent in 2023, compared to the WHO estimation of 5-15 percent for the region. Most pediatric TB cases are clinically diagnosed by pediatricians. However, TB contact screening and the coverage of TB preventive treatment are suboptimal. According to the WHO Global TB Report

2024, only 19 percent of estimated household contacts of bacteriologically confirmed TB cases received preventive treatment in 2023. Although the country has a sufficient number of GeneXpert machines, they are underutilized due to various factors, including electricity disruptions, shortages of cartridges, and uneven distribution of GeneXpert locations.

Afghanistan's natural disasters and poverty have led to high levels of psychological trauma.

According to the 2023 United Nations Summary Report of Country Wide Women’s Consultations, more than two-thirds of Afghan women reported feelings of anxiety, isolation, and depression. The report also stated that women spoke of psychological issues such as insomnia, loss of hope and motivation, fear, aggression, and suicidal ideation. Gender-based violence (GBV) is primarily associated with women and children due to cultural norms and gender inequalities. It can affect the health and wellbeing of women and children, leading to various physical and mental health problems. Survivors may suffer from injuries, pregnancy complications, sexually transmitted infections, depression, post-traumatic stress disorder, and in extreme cases, even death. Despite the mental health challenges faced by many women in Afghanistan, the country faces severe shortages of mental health professionals and infrastructure. Cultural barriers and restrictions on education and employment further limit women's ability to access mental health and psychosocial support services

(MHPSS).

Today, the health sector in Afghanistan continues to face significant challenges, marked by poor https://www.stoptb.org/static_pages/AFG_Dashboard.html

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity quality health care services, high costs, long distances to facilities, and a lack of resilience to respond to emergency health situations. Additionally, a considerable data vacuum exists on demographic, social and economic indicators because there has been no census conducted in the past decade. Population projections and sampling frames do not count migrant populations, making them “invisible” in reports on catchment area populations and social, demographic and economic conditions. At a population level, poor health behaviors and practices due to low literacy and educational levels, coupled with cultural and social norms, are additional challenges.

Afghanistan's community-based health care network has developed gradually over the past two decades in rural areas to support the Basic Package of Health Services (BPHS) program. More than

28,000 volunteer community health workers (CHWs) - approximately half of them female - are active, providing basic health care to the communities they live in, educating and mobilizing communities, and referring patients to the nearest health facilities. CHWs also receive support and supervision from the health facilities to which they report. The Community-Based Health Care

Strategy (2015–2020) for urban contexts was adapted but not fully implemented due to a lack of resources. This model of urban community health workers was adapted by some health sector partners in targeted urban areas through the creation of urban health posts, recruiting urban community health workers (uCHWs), and adapting CHWs’ training and reporting tools. However, this has not been scaled up uniformly. Community health workers are crucial for the successful implementation of health and nutrition services at the primary and secondary levels within BPHS and urban areas. Effective health service implementation depends upon improving and fostering partnerships between community members and health facility staff.

The private health care sector in Afghanistan has grown steadily during the last two decades, and at the end of 2022, 205 private hospitals and 164 private outpatient clinics were operating in the capital of Kabul (Health Sector Transition Strategy, 2023-2025). The private sector is historically concentrated in urban areas and reliant on networks of general practitioners who practice in both private and public hospitals. There is weak accountability, limitations in oversight, poor coordination, and vertical programming. According to the 2021 Afghanistan National Health

Account Report, out-of-pocket (OOP) expenditure in health was reported to be 77.2 percent in 2021, with spending of $97.80 per capita. The share and level of per capita OOP expenditure in

Afghanistan are significantly higher than in other South Asian and lower-income countries. High

OOP spending is attributable to the lack of drugs in public health care facilities; demand for private services due to perceived better quality and availability of laboratory equipment and doctors; and the limited scope of the BPHS/essential package of hospital services (EPHS) to respond to a broad range of care and needs (Afghanistan National Health Account Report 2021).

Taliban edicts restricting the movement, education, and employment of women affect the availability of, access to, and utilization of quality health services. Among these restrictions, women are banned from traveling long distances and entering health facilities without a mahram or male custodian. The exclusion of girls from secondary school, and the subsequent banning of women from public and private universities, present barriers for females to enter the health workforce. The current and potential long-term shortage of competent female nurses, midwives, and doctors will negatively impact the ability of women and children to safely receive quality care. New Taliban edicts also limit household-level health services and mass media health promotion activities that feature women. Overall, harmful gender and social norms, including the low social status of

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity women, the tradition of early marriage, and norms around family size and child spacing, shape beliefs and behaviors and impede women’s decision-making and empowerment.

c) Operational Context

There is currently no internationally recognized government in Afghanistan with which USAID can collaborate. Basic service delivery in more than 2,300 health facilities nationwide is funded by the

Afghanistan Resilience Trust Fund (ARTF), a multi-donor trust fund administered by the World

Bank and Asian Development Bank (ADB). Both funders implement their programs through

UNICEF, which contracts out service delivery to local and international non-governmental organizations (NGOs) at the provincial level. USAID contributes funding to ARTF and also supports wraparound technical assistance to its Health Emergency Response (HER) project. The

Ministry of Public Health (MoPH) funds service delivery mainly at the tertiary level, including national, regional and specialty hospitals. USAID supports capacity building for health care providers at some of these hospitals.

The operating environment in Afghanistan under the Taliban has been marked by frequent edicts and restrictions that impact the ability of national and international NGOs to implement activities.

Implementing partners are required to sign MoUs with sectoral ministries, which can be a time-consuming process. Female staff must be accompanied by a mahram when commuting and have separate spaces in offices and/or when attending training sessions. Taliban authorities frequently visit NGO offices to monitor operations or collect information.

USAID’s activities in Afghanistan operate within a legal context that includes statutory restrictions on assistance to the Taliban; Office of Foreign Assets Control (OFAC) and UN sanctions; and significant oversight. USAID implementing partners must comply with applicable laws and the terms of the OFAC General Licenses that permit operations in Afghanistan, particularly when it is necessary to engage with government authorities. USAID/Afghanistan expects to be informed of attempted interference by the Taliban or government authorities and may require an additional level of review and approval for certain types of engagement.

d) Donor Collaboration

The commitment of donors and international organizations to work together has been essential for maintaining health services in Afghanistan. The Health Strategic Thematic Working Group (H-

STWG) brings together donors to pursue harmonized approaches and maximize the use of resources. Other major health donors include the Global Fund to Fight HIV, TB and Malaria, the

ADB, the European Union, the Foreign Commonwealth and Development Office, Global Affairs

Canada, and Gavi the Vaccine Alliance.

3. Connection to USG and USAID Strategic Priorities

The IHI Activity will advance the U.S. Integrated Country Strategy for Afghanistan, Mission

Objective 2.3: Sustain vulnerable Afghans’ safe access to basic services that meet minimum quality standards while messaging that such assistance is not indefinitely sustainable.

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

The Activity will also support the overarching goal of the new USAID/Afghanistan Strategic

Framework 2024-2027: Advance the resilience of Afghan people, especially women and girls.

This Activity will directly contribute to and advance the following USAID special objectives and intermediate results (IRs):

Special Objective 1: Promote Fundamental Freedoms, Rights, and Inclusion

● IR 1.1 Strengthen the capacity of local organizations

Special Objective 3: Improve Health Outcomes for Women and Children

● IR 3.1 Improve access to and quality of health care

To a lesser degree, it will also contribute to IR3.2 to prevent infectious disease outbreaks through early detection.

The IHI Activity will also advance the Mission’s cross-cutting priorities on gender and localization.

4. Theory of Change

The theory of change, depicted in Figure 1 below, states that IF equitable access to health is increased, quality of services improved, and healthy behaviors and practices improved, THEN we will see improved outcomes in a variety of priority areas, such as facility childbirths, breastfeeding, full vaccination, health seeking behaviors, TB detection and effective treatment, and mental health screening and counseling. These outcomes, together, will RESULT IN a broader impact as measured in longer-term positive changes in health at the population level, especially in women and children, including reductions in maternal, neonatal, and child mortality; malnutrition; vaccine-preventable diseases; TB prevalence; and mental health cases.

Figure 1. Theory of Change

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

5. Strategic Consideration and Guiding Principles

Implementation of the IHI Activity will be guided by a number of strategic considerations and guiding principles, which USAID has identified as important for an effective approach. These include:

● Adaptability and flexibility. Working in Afghanistan requires a high degree of adaptability and flexibility due to the complex and often unpredictable environment. Although the security environment has significantly improved in recent years, sporadic attacks by opposition groups to the Taliban regime, kidnapping, and theft still occur. The IHI Activity will need to assess how to comply with new Taliban edicts when they occur. The IHI

Activity should also seek to use approaches that are suited to the current situation and be able to adjust programming when the context warrants.

● Locally appropriate and gender sensitive interventions. Restrictions on the movement of women and girls impact their ability to seek health services and also impact female staff trying to get to work. Afghanistan is a male dominated society, and decision-making is made by men in many aspects of life, including family health care. Rural populations are often more influenced by religious beliefs than urban populations. Men and religious leaders’ involvement in health care programs have resulted in positive outcomes. The implementation of the IHI Activity requires a deep understanding of local customs and social/cultural/religious norms, which are essential to building trust and collaborating with local communities and partners.

● Building on previous investments. In Afghanistan’s fragile context, continuity and cumulative progress are critical for improving health outcomes. Prior health initiatives provide critical insights into what works and what doesn’t in Afghanistan’s cultural and political context. In addition, building on previous knowledge helps refine approaches, avoid repeating mistakes, affords the opportunity to scale proven solutions, and makes more efficient use of limited resources.

● Private sector engagement. While Afghanistan's private sector is largely unregulated, it has the potential to fill critical gaps in health service delivery. Almost 53 percent of the national population goes to private providers for medical attention (Afghanistan Welfare

Monitoring Survey, 2022). USAID has been one of the few donors that supports private sector health care providers in Afghanistan in an effort to increase access to quality services, and this focus continues under the IHI Activity.

● Technical capacity building of local organizations. Local organizations, such as those providing health services, youth-led organizations, gender-equity focused organizations, non-governmental professional associations, social marketing organizations, and private actors are crucial for leading local development efforts in Afghanistan, including advocating for behavior change and improving access to and quality of services. The IHI Activity should consider supporting the technical capacity building of local organizations and their staff to strengthen their skills and abilities to be community leaders, to achieve their goals, and to be more effective and relevant within their communities. USAID recognizes that

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity sustainable development comes with strengthened institutions; however, in the absence of a recognized government, technical assistance and capacity building for government institutions and personnel requires express approval from USAID in advance and requires vetting of recipients of such technical assistance or capacity building.

6. Goal, Objectives and Anticipated Results

The overall goal of the IHI Activity is to improve health outcomes for women and children. USAID does not intend to mandate a particular approach, specific actions, or delivery of specific services to achieve the proposed activity goal, objectives, and intermediate results but rather expects the potential applicants to propose an evidence-based approach to achieving them.

Objective 1: Increase Equitable Access to Health Services

IR 1.1 High impact interventions at facility and community levels scaled up

IR 1.2 Access to health services and products through the private sector improved

IR 1.3 Referral systems from community to health facilities and between facilities strengthened

Objective 2: Improve the Quality of Health Services

IR 2.1 Innovative quality improvement tools and approaches adapted and scaled up

IR 2.2 Health care provider competence and confidence to provide quality, respectful care improved

IR 2.3 Private sector health data integrated into DHIS2

Objective 3: Improve Healthy Behaviors and Health Care Seeking Practices

IR 3.1 Innovative behavior change approaches developed and implemented

IR 3.2 Community engagement and social accountability strengthened

Program Objective 1: Increase Equitable Access to Health Services

Access to services remains difficult largely due to cultural constraints, costs of services, and transportation required to reach distant health care facilities. People in rural areas need to travel vast distances, which they often cannot afford, and which could take days. Restrictions on women’s and girls’ movements without a mahram has reduced their access to healthcare services. There is also limited availability of essential medical supplies at health facilities both in the public and private sectors, and the bans on female higher education could result in a shortage of female doctors, midwives and nurses. The health system in Afghanistan must also deal with the challenges of providing healthcare to internally displaced persons and returnees from neighboring countries in urban settings, especially in Nangarhar, Herat and Kandahar, which are entry points for returnees from Pakistan and Iran. It is unlikely that the IHI Activity will be able to change all of these conditions, but access to health services is critical so the Applicant is encouraged to find innovative solutions to increase access.

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity

The IHI Activity should consider opportunities to develop and implement strategies to address systemic barriers to providing equitable care by identifying and addressing health and social determinants, in order to improve access to life saving health services.

Intermediate Results:

1.1 High Impact Interventions at Facility and Community Levels Scaled up:

The IHI Activity should build on USAID’s past investments in Afghanistan, proven high impact interventions, and best practices to improve health outcomes and contribute to the reduction of maternal and child morbidity and mortality. Expanding alternative models of care, offers opportunities to bring services closer to clients, using creative solutions to remove barriers for the most vulnerable populations and increase access to essential services.

Examples of high impact interventions that have been implemented in the past include essential newborn care, in particular skin to skin and breastfeeding support; use of chlorhexidine for newborn cord care for home deliveries; respectful labor and childbirth care; postpartum family planning counseling and services; establishing family planning and newborn care corners in delivery rooms;

integration of nutrition into maternal and child health services; and integrated management of childhood illnesses. High impact, low-cost health interventions at the community and health facility levels will focus on family planning and reproductive health (FP/RH); maternal, newborn, and child health (MNCH); nutrition; TB; and mental health.

1.2 Access to Health Services and Products through the Private Sector Improved:

The private sector primarily focuses on secondary and tertiary health services in urban population centers, with limited emphasis on the primary and preventive health care needs of the general population. This focus further restricts access to essential quality health services for underserved populations in urban areas. While high user fees and costs for medical treatment obtained in the private sector pose significant challenges for the people with low income, one can successfully implement strategies to offer subsidized health care for eligible families to benefit both health providers and low-income clients.

The IHI Activity will continue to support the private sector and build on the current social marketing and social franchising activities to increase demand for, access to, and use of high-quality health commodities and health services, in particular for FP/RH, MNCH, and nutrition. Socially marketed products include oral and injectable contraceptives, condoms, misoprostol, chlorine solutions and tablets for water disinfection, oral rehydration solution (ORS) and zinc tablets for diarrhea treatment, iron folic acid tablets for anemia prevention, and nutrition sprinkles. Condoms will be donated by USAID; all other products will be procured by the social marketing program using its program revenues. The IHI will maintain or expand geographic coverage, and the product basket as needed to improve maternal and child health outcomes. IHI will also support and expand, as feasible, social franchising and networking between providers and health facilities, which has been implemented with USAID support in recent years to improve community access to health care, especially for women and children.

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1.3 Referral Systems from Community to Health Facilities and between Facilities

Strengthened:

There are gaps in the continuity of care and weak referral pathways from the community level to facility-based primary, secondary, and tertiary care. This is particularly evident in urban settings.

Clients often directly seek services at facilities or hospitals as they are known to have available staff and medicines. This utilization pattern is also true for clients coming from surrounding regions, resulting in overburdened specialty hospitals in big cities and underutilized health facilities at lower levels. A strong referral system at various levels—from community to primary, secondary and tertiary levels—and across the public and private sectors, will help families and needy populations access the next level of care as appropriate. The IHI Activity should consider approaches to engage with stakeholders including BPHS and EPHS implementers, the private sector, and communities to establish strong and active referral and counter referral systems from the community to the facility and between facilities across different levels of the health system.

Objective 1 Illustrative Activities:

The following activities are meant to be examples of possible ways to achieve the Intermediate

Result. The Applicant should identify the best strategies to obtain results and is not required to use any or all of the illustrative activities listed below.

1. Adapt and expand a core set of proven high impact MNCH, FP/RH, nutrition, MHPSS, and

TB interventions, including self-care (e.g. home-based practices) as needed.

2. Adapt and expand innovative approaches to reduce gender, cultural, age-related, and other barriers to access basic health and nutrition services and products.

3. Support implementation of affordable primary health care packages in private hospitals.

4. Strengthen market development approaches to increase availability of priority products, including contraceptives (including long-acting reversible contraception) with linkages between social marketing, public, and private sectors.

5. Strengthen implementation of light-touch social franchising models to promote quality essential products and improve priority interventions and referral systems, using the network of CHWs and midwives.

6. Strengthen community-to-facility referral systems, including transportation, emergency calls, and follow-ups in urban and rural areas, including in the private sector.

7. Work with the private sector to establish/strengthen their current community-based programs and establish health camps to promote health care and improve referrals, including for MHPSS.

Program Objective 2: Improve the Quality of Health Services:

The recently improved security situation in the country has led to better access to health services, but the quality of care is poor both in public and private health facilities and not trusted by the public. Quality of care is hampered by shortfalls in human resources, infrastructure, medicines, protocols and guidelines, and quality assurance mechanisms. The availability and balance of competent health care providers across Afghanistan have remained challenges over the past two decades, despite significant investments in the health sector. The World Health Organization has

NOFO 72030625RFA00001 Integrated Health Initiative (IHI) Activity highlighted a critical shortage of personnel and a gender imbalance in healthcare workers. Recent

Taliban restrictions on women's movement have further complicated the distribution and retention of female health workers.

Maternal and neonatal death audits are not regularly conducted in Afghanistan, yet they hold significant potential for uncovering the underlying causes of these deaths. The IHI Activity should consider supporting national surveys to collect population-based data, which will contribute to more informed strategies for improving maternal and neonatal health.

In 2023, USAID donated two oxygen plants to alleviate the shortage of medical oxygen for patients in Nangarhar and Kandahar regional hospitals. The IHI Activity should consider opportunities to support maintenance and operation of these oxygen plants to ensure quality of health services.

Resources are insufficient to accommodate gender-sensitive care, such as separate waiting areas for male and female clients and private areas to deliver MHSS. The availability of basic services varies and often is provided by health workers with substandard knowledge and skills. These issues impact the receipt of adequate care and should be considered under the IHI Activity.

The Afghanistan Health Management Information System (HMIS) has improved over the last 20 years in terms of content and timely uploading of information. The focus on data collection systems should now be to continue improving interoperability, improve overall capacity to analyze and use data at management and implementation levels for evidence-based service delivery planning and national level decision-making, and ensure the public HMIS includes private sector data. The private sector has been reluctant to send data because it can increase their tax liability. If they do send data, they are of questionable quality and do not follow national guidelines.

2.1. Innovative Quality Improvement Tools and Approaches Adapted and Scaled-Up

Best practices and performance standards on FP/RH, MCH, TB, and nutrition services are not disseminated in a timely or uniform manner from the central level to provincial levels in

Afghanistan. Furthermore, there is weak regulation of and coordination with the private sector.

Effective monitoring and supervision, as well as quality assurance and quality improvement approaches, are limited for public sector providers and there is little interaction or collaboration with the private sector.

Improving respectful maternal and newborn care is a critical contributor to ending preventable maternal and newborn deaths. The IHI Activity should adapt and scale up the most effective approaches, tools and processes, such as patient flow, client privacy, and confidentiality to improve the quality and utilization of priority programs on FP/RH, MCH, nutrition, MHPSS, and TB, in an integrated manner. In close collaboration with humanitarian partners, the Activity should seek to support early detection of malnutrition and facilitate timely treatment. The IHI Activity should also consider innovative approaches to solicit actionable client feedback in a constructive format to integrate into improvement plans and priorities. The Activity should aim to improve client satisfaction and confidence with both public and private health care services.

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2.2 Health Care Provider Competence and Confidence to Provide Quality Respectful Care

Improved

There are gaps in the knowledge and skills of health care providers, and the quality of counseling remains poor. For instance, a USAID Quality of Care Study conducted in 2016 showed that counseling on healthy timing and spacing of pregnancy was only provided in 23 percent of antenatal care consultations; only 36 percent were asked about danger signs such as headaches or visual disturbances; and 36 percent received the tetanus toxoid vaccine. The quality of PNC is also substandard; for example, only 50 percent of women received counseling on the importance of exclusive breastfeeding and 33 percent on when to return for the next PNC visit.

The IHI Activity should consider ways to increase and ensure the consistency of public and private health care providers’ knowledge and competency in critical evidence-based FP/RH, MNCH, MHPSS, nutrition, and TB interventions. The Activity can be an opportunity to use a wide range of strategies to ensure providers have the knowledge and skills to provide respectful counseling and services through practical approaches to go beyond standard cascade training models. The IHI

Activity should not directly hire staff for health facilities to deliver services or provide salary top-ups or similar incentives.

There are opportunities to strengthen the quality of care and health provider performance using information communication technology (ICT) solutions that have been tested in Afghanistan or similar contexts, as well as to promote technology-based platforms that connect tertiary with lower-level facilities in cities to improve learning, data-driven decision-making and clinical outcomes.

Last Paragraph from Objective 2.2 has been removed.

IR 2.3 Private Sector Health Service Delivery Data Integrated into DHIS2

Almost all public and some private health facilities report to the national DHIS2 platform in the

HMIS. However, the private sector has historically been reluctant to share this information with the public sector due to financial and regulatory implications. These data, however, are critical for program management and decision making. The IHI Activity will support the private sector to report timely and quality data from urban and rural areas into the public sector DHIS2, conduct regular data quality assessments within their health facilities, and implement mechanisms to review and use data for decision-making and performance reviews.

Private sector individual service providers and clinical teams also need to improve their skills to better manage services, conduct outreach activities to surrounding communities, accurately record clinical data, identify and monitor service delivery indicators, and analyze service delivery trends to help them forecast and plan, and better serve their clientele.

Objective 2 Illustrative Activities:

Result. The Applicant should identify the best strategies to obtain results and is not required to use any or all of the illustrative activities listed below:

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