NOFO 72061524RFA00004_Amd 02_Final.pdf

DATE:

SUBJECT:

May 6, 2024

Notice of Funding Opportunity Number (NOFO) 72061524RFA00004, Amendment No. 02, USAID Kenya and East Africa (KEA) Social Behavior Change (SBC) Activity

Dear Prospective Applicants:

The purpose of Amendment No. 2 to the NOFO is as follows:

1. Provide answers to questions raised during the pre-application conference on April 22, 2024 (see Appendix 1);

2. Revise application instructions for Phase 2 and 3 under Section D (see highlighted changes in Appendix 2); and

3. Revise merit review criterion for Phase 3 under Section E (see highlighted changes in Appendix 2).

This amendment does not obligate USAID to execute an award, nor does it commit USAID to pay any costs incurred in the preparation and submission of applications. Furthermore the U. S.

Government reserves the right to reject any and all applications, if such action is considered to be in the best interest of the U. S. Government. All other terms and conditions remain unchanged.

Sincerely, /s/

Sandra Jansen Agreement Officer Office of Acquisition & Assistance USAID Kenya and East Africa

Notice of Funding Opportunity Number 72061524RFA00004. Amendment No. 02 USAID/KEA Social Behavior Change Activity Appendix 1. Questions and Answers

QUESTIONS AND ANSWERS

1. Do we have to cover all 7 health sector areas?

USAID Response: Applicants should propose a technical approach that would lead to achievement of objectives and results for all disease areas given that potential windows of opportunity may include buy-ins to the Activity from malaria, HIV, FP/RH, MNCH, TB, and GHS. From the integration's guiding principle in the NOFO,the Activity is encouraged to explore the design and implementation of integrated SBC interventions.

2. Do proposals need to focus on ALL areas (Tb, HIV, Maternal health, pregnancy and HIV)?

Or can we focus on a specific health area?

USAID Response: See response to question #1.

3. After concept submission, will all applicants receive the outcome of the results?

USAID Response: Yes. Applicants will be notified of whether or not their concept paper is selected to proceed to Phase 2.

4. Do you expect a social marketing component of products in this NOFO

USAID Response: Applicants should propose a technical approach that would lead to achievement of objectives and results.

5. Can a local organization partner with an international organization ?

USAID Response: Applicants may propose a partnering strategy that aligns with their proposed technical approach.

6. Can the application just respond to a given region or County and leave out the National level engagement?

USAID Response: Under Section A, the Geographical Scope section of the NOFO states that the Activity will support activities at the national and sub-national levels in Kenya.

The section further proposes the two modalities of implementation at the national and subnational levels respectively.

7. Could you please provide information on whether there is a standard concept paper template available?

USAID Response: Guidance on the preparation of the concept paper is provided in Section D of the NOFO.

Appendix 1. Questions and Answers

8. Do we need to show how we will work with the USAID partners in the concept note?

USAID Response: Applicants should propose a technical approach that would lead to achievement of objectives and results.

9. The NOFO requires alignment with GoK priorities; one of those is the Community Health Strategy. However IR 3 focus on only national level- does this deliberately require CHS to not be involved

USAID Response: The NOFO states that “Generally, the Activity will implement activities associated with IR 1 and IR 2 at the national and sub-national levels and activities associated with IR 3 and IR 4 at the national level.” The NOFO further proposes the two modalities of implementation at the national and subnational levels respectively.

However, as per the NOFO guiding principles the Activity should establish strong and active collaboration and coordination between members of the target populations, communities, county governments, private sector entities, community-based organizations, faith-based organizations, civil society organizations, MOH, and other relevant ministries, other USG-funded activities, and other development partners.

Opportunities for collaboration and coordination include but are not limited to co-creation, joining planning and management, joint monitoring, and joint support supervision.

10. Is there a target group and age range for the youth population?

USAID Response: Applicants may propose targets based on their understanding of the context and their proposed technical approach.

11. How likely is it that the $8.7m through additional modules will be availed through the life of the program?

USAID Response: Subject to funding availability and at the discretion of the Agency, USAID intends to provide up to $14,950,000 in total funding over a five-year period.

12. Should the consortium be presented at concept note stage or at full technical application?

USAID Response: Please see Section D of the NOFO for detailed guidance on preparation and submission of the concept paper.

13. How many INGOs can be in a consortium?

Appendix 1. Questions and Answers

USAID Response: See response to question #5.

14. After concept submission, will all applicants receive the outcome of the results?

USAID Response: See response to question #3.

15. Do you expect the winning organization(s) to engage in an active advocacy programme with the Government of Kenya?

USAID Response: Applicants should propose a technical approach that would lead to achievement of objectives and results.

16. Are NGOs from various sectors such as governance and democracy eligible for participation, or is participation restricted to NGOs solely focused on health-related areas?

USAID Response: Eligibility of the principal applicant is restricted to local Kenyan entities.

Please see Section C of the NOFO for additional eligibility requirements.

17. We are in a consortium made of organizations that meet the experience needed by NOFO. Can an organization which has not met the full capacity required by NOFO make an application as the prime partner?

USAID Response: See response to question #16.

18. How many applicants/consortiums will be awarded for this grant?

USAID Response: USAID intends to award one (1) Cooperative Agreement pursuant to this notice of funding opportunity.

19. Is there a page limit for the annex?

USAID Response: Please see Section D of the NOFO for detailed guidance on preparation and submission of the concept paper.

20. Why can't the issuance of Unique Entity Identifier and SAM be expedited to take at least one week? Are there technical hitches to the issuance of the same?

USAID Response: USAID does not manage the UEI and SAM registration process.

Applicants are not required to obtain a UEI and complete SAM registration in Phase 1:

submission of concept papers. However, please be advised that the registration process may take many weeks to complete. Therefore, applicants are encouraged to begin the

Appendix 1. Questions and Answers process early. If an applicant has not fully complied with the requirements above by the time USAID is ready to make an award, USAID may determine that the applicant is not qualified to receive an award and use that determination as a basis for making an award to another applicant.

21. What happens if say HIV doesn’t come through with expected funding, would it be ok to use say malaria or MCH funds to do the HIV component?

USAID Response: Applicants should propose a technical approach that would lead to achievement of objectives and results for all disease areas given that potential windows of opportunity may include buy-ins to the Activity from malaria, HIV, FP/RH, MNCH, TB, and GHS. Specific activities in health areas during implementation will be guided by the work plan.

22. How many awards do you anticipate to release for this opportunity?

USAID Response: See response to question #18.

23. Is there a requirement to split available budget amounts across equally among all the health areas?

USAID Response: Funding available for each health area will be determined during implementation.

24. Is it OK to have a local entity as the prime applicant with several INGOs as subs?

USAID Response: See response to question #5.

25. When do we get the most recent amendments?

USAID Response: All amendments to the NOFO are posted on grants.gov.

26. Can a local organization prime and be in a sub in another submission?

USAID Response: An entity may only submit one concept paper as the prime applicant but may be proposed as a subrecipient in another concept paper.

27. Is there weighting in terms of funding available for each of the specific sectors, for example GHS HIV, TB, WASH, etc.?

USAID Response: See response to question #23.

Appendix 1. Questions and Answers

28. Are we expected to have a products component and social marketing

USAID Response: See response to question #4.

29. Is there weighting in terms of funding available for each of the specific sectors, for example HIV, TB, WASH, etc.?

USAID Response: See response to question #23.

30. Should the application address SBC strategies for all the focus areas?

USAID Response: See response to question #1.

31. Kindly clarify the number of pages of the concept paper because you have just mentioned it must be 6 pages while the NOFO says a Max of 9 pages. Which is which?

USAID Response: See response to question #19.

32. Can local learning institutions bid as primary applicants?

USAID Response: See response to question #16.

33. Can we submit the concept in kiswahili?

USAID Response: No. Concept papers must be submitted in English.

34. Is there a limit to the numbers of international NGOS who can be in one consortium led by a local partner?

USAID Response: See response to question #5.

35. What is the project duration?

USAID Response: The award is anticipated to be issued for a five-year period.

36. Can we get an idea what proportion of the funding covers the various technical areas for the full award? What happens if most addresses one specific area? Will that affect the work plan implementation?

USAID Response: See response to question #21 and #23.

Appendix 1. Questions and Answers

37. Because most of the programs Kenya Health Partnerships for Quality Services (KHPQS) will be ending soon, how has USAID envisaged this support, considering that the SBC program may start in October 2024.

USAID Response: The end of the KHPQS activities are not anticipated to affect the SBC Activity start date.

38. Do USAID have impact indicators/goals or do we need to describe the results in consent note?

USAID Response: Applicants may propose targets based on their understanding of the context and their proposed technical approach, also as per the NOFO informing the Proposed Logic Framework, that would lead to achievement of objectives and results.

39. Kindly guide on which amount would be ideal to quote: do we plan with 6M or with 14M? Would one be penalized for planning with 14M?

USAID Response: Applicants must not quote or submit a budget in Phase 1 for the concept paper. As stated in Section B of the NOFO, USAID intends to provide up to $14,950,000 in total funding subject to funding availability and at the discretion of the Agency. The base amount for this award is expected to be approximately $6.25 million.

In addition to this base amount, the Cooperative Agreement will include an unfunded budget allocation for three (3) opportunity modules of up to $8.7 million, inclusive of indirect costs. This unfunded budget allocation for the opportunity modules is not guaranteed

40. Is there a pre award survey template an organization can be undertaking as part of preparation for the award?

USAID Response: The need for a pre-award survey will be determined by the Agreement Officer (AO). If needed, the AO would establish a formal survey team 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. Organizations new to working with USAID may find useful resources at www.workwithusaid.gov, including a self-assessment pre-engagement survey.

41. The NOFO states three modules worth $8.7m might be added to the base value of $6.25m. Will this definitely be three modules or could it be more or less than three and how will modules be decided?

Appendix 1. Questions and Answers

USAID Response: Please see Section B.1 of the NOFO.

42. Can a CBO apply or just NGOs?

USAID Response: See response to question #16.

43. Is there a template for the concept paper presentation?

USAID Response: See response to question #7.

44. Under "Capacity Strengthening": the call indicated Developing behavior change communication training On .....human-centered design training curriculum. Who Should the curriculum target?

USAID Response: See response to question #10.

45. Does the eligibility of ownership of a local entity apply to NGOs since no one owns them?

USAID Response: No, it does not.

46. Should we be designing our program approach and log frame results for $6.25m or $14.95m?

USAID Response: See response to question #39.

47. What is the definition of base amount and opportunity modules?

USAID Response: The base amount is the anticipated funding amount available for the five-year duration of the award. The opportunity modules are anticipated additional funding through buy-ins by different program health areas that may become available during the implementation of the award. Total funding of the award is subject to funding availability and at the discretion of USAID.

48. The portal grants.gov indicates apply here or we stick to the email

USAID Response: The "Apply" button on grants.gov is not activated. Applicants must follow the submission guidance and instructions provided in the NOFO.

49. Are organizations with local Kenyan Boards and registered in Kenya but with International offices considered local?

Appendix 1. Questions and Answers

USAID Response: See response to question #16.

50. Can the concept be in Kiswahili?

USAID Response: See response to question #33.

51. Could you talk more about the logical framework?

USAID Response: Given the Theory of Change and Results Framework in Section A, the Applicant must include an illustration of a proposed Logic Framework detailing their understanding and interpretation of the program description, proposed interventions and how they will lead to desired goal, results, and intermediate results described in the Results Framework.

52. Are links allowed in the 9 page limit?

USAID Response: USAID will not review any materials submitted in excess of the sections and page limits described in Section D of the NOFO.

53. Is SAM and EUI required for sub recipients?

USAID Response: Please refer to Section C of the NOFO.

54. For the Technical approaches, are we allowed to align it with the IRs from 1 to 4?

USAID Response: Applicants should propose a technical approach that would lead to achievement of objectives and results.

55. Can we include links to the document?

USAID Response: See response to question #52.

56. What is the expected depth of the technical proposal for the concept papers?

USAID Response: Applicants should propose a technical approach, and the appropriate depth noting the page limits, that would lead to achievement of objectives and results.

57. Please clarify the geographical areas of focus for this SBC Activity.

USAID Response: The Geographical Scope section of the NOFO states that the Activity will support activities at the national and sub-national levels in Kenya. The section

Appendix 1. Questions and Answers further proposes the two modalities of implementation at the national and subnational levels respectively. Additionally the NOFO states the expected Geographical focus by health area.

58. I am preparing the "Phase 1: concept plan" and was wondering if I could submit one attachment in this submission? We have only 9 pages and 2 annex pages. Could I submit a technical bulletin as an attachment?

USAID Response: All applicants must follow the submission and application instructions under Section D. As stated on p. 24 of the NOFO, USAID will not review any pages in excess of the page limits noted.

Appendix 2.

Issue Date: Wednesday, April 3, 2024 Deadline for Questions: Thursday, April 18, 2024 Pre-Application Conference: Monday, April 22, 2024 Closing Date: Wednesday, May 8, 2024 Closing Time: 12 noon East Africa Time

Subject: Notice of Funding Opportunity (NOFO) Number: 72061524RFA00004, Amendment 02

Program Title: USAID Kenya and East Africa (KEA) Social and Behavior Change (SBC) Activity

Federal Assistance Listing Number: 98.001

Ladies/Gentlemen:

The United States Agency for International Development (USAID) is seeking applications for a cooperative agreement from qualified entities to implement the USAID/KEA SBC Activity. Eligibility for this award is restricted to Kenyan organizations.

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 C 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 notice of funding opportunity and to ensure that the NOFO has been received 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 Helpdesk at 1- 800-518-4726 or via email at support@grants.gov for technical assistance.

USAID may not award to an applicant unless the applicant has complied with all applicable unique entity identifier and System for Award Management (SAM) requirements detailed in Section C.3. The registration process may take many weeks to http://www.grants.gov/ mailto:support@grants.gov complete. Therefore, applicants are encouraged to begin registration early in the process.

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

Issuance of this notice of funding opportunity 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, Sandra Jansen Agreement Officer

TABLE OF CONTENTS

SECTION A: PROGRAM DESCRIPTION 1

SECTION B: FEDERAL AWARD INFORMATION 15

SECTION C: ELIGIBILITY INFORMATION 19

SECTION D: APPLICATION AND SUBMISSION INFORMATION 21

SECTION E: APPLICATION REVIEW INFORMATION 34

SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION 35

SECTION G: FEDERAL AWARDING AGENCY CONTACT(S) 42

SECTION H: OTHER INFORMATION 43

ANNEX 1 - SECTION A PROGRAM DESCRIPTION (KISWAHILI) 44

ANNEX 2 - STANDARD PROVISIONS 58

ANNEX 3 - ABBREVIATIONS AND ACRONYMS 60

ANNEX 4 – INITIAL ENVIRONMENTAL EXAMINATION (IEE) 64

SECTION A: 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 F.

I. ACTIVITY GOAL

The USAID/KEA SBC Activity (“Activity”) will support individuals (including service providers), households, and communities to adopt and maintain the practice of priority health behaviors by (IR 1) identifying and addressing individual, social, and structural factors that influence priority health behaviors; (IR 2) increasing the availability and use of evidence for design, implementation, monitoring, evaluation, and learning; (IR 3) strengthening Government of Kenya (GOK) systems, structures and policies to improve coordination, collaboration, and learning for SBC interventions; and (IR 4) strengthening the individual, organizational, and systems level technical capacity to design, implement, and monitor SBC interventions.

The Activity will contribute to the achievement of the development objectives outlined in the USAID/Kenya and East Africa (KEA) Country Development Cooperation Strategy (CDCS)1, as well as to the USAID Bureau for Global Health’s strategic priorities of preventing child and maternal deaths; achieving and sustaining epidemic control; and combating infectious diseases2.

II. BACKGROUND AND DEVELOPMENT CHALLENGES

Across health areas, success depends on human behavior. The ability, opportunity, and motivation of individuals (including service/health providers), households and communities to adopt and maintain the practice of priority behaviors is influenced by individual, social, and structural factors. Evidence-based, theory-informed social and behavior change (SBC) interventions increase the ability, opportunity, and motivation of individuals (including health service providers) to adopt and sustain priority behavior by addressing the internal, individual , social, and structural factors that influence those priority behaviors. SBC is defined by the USAID Bureau for Global Health as “a systematic, evidence-driven approach to improve and sustain changes in behaviors, norms, and the enabling environment. SBC interventions address the individual, social, and structural factors3 that influences the practice of target behaviors. SBC is grounded in several disciplines, including systems thinking, strategic communication, marketing, psychology, anthropology, and behavioral economics”.

1 https://www.usaid.gov/kenya/cdcs 2 https://www.usaid.gov/global-health 3 https://thinkbigonline.org/action/document/download?document_id=416 https://www.usaid.gov/kenya/cdcs https://www.usaid.gov/global-health https://www.usaid.gov/global-health https://thinkbigonline.org/action/document/download?document_id=416

A. Health Sector Challenges

Malaria

Kenya is moving towards achieving the 2023 Malaria target of increasing utilization of appropriate malaria interventions to at least 80 percent. However, there are opportunities to address further the barriers to the increased utilization of appropriate malaria interventions using SBC. Some of the most important human behaviors associated with malaria control and elimination include use of an insecticide treated net (ITN), care-seeking for fever, attendance at antenatal care (ANC) clinics, use of intermittent preventive treatment of malaria in pregnancy (IPTp), and adherence to national guidelines. The prevalence of these behaviors among priority populations varies, as do the individual, social, and structural factors that influence these behaviors. In 2022, U.S. President’s Malaria Initiative (PMI) Kenya supported the implementation of the Malaria Behavior Survey (MBS)4 to better understand the prevalence of these behaviors and the factors that influence the practice of these behaviors. According to the MBS, specific to ITN use, almost one third (31%) of available ITNs in the household were not used the night preceding the survey, and only 80 percent of individuals in households with sufficient access to ITNs (one ITN per two members) used them. Specific to care-seeking for fever, according to the MBS, among caregivers, 33 percent reported that a child under age five had a fever in the two weeks preceding the survey and 50 percent of children under age five with fever reportedly received both prompt and appropriate care. Specific to ANC attendance and IPTp uptake, according to the MBS, among women with a live birth in the two years preceding the survey, 82 percent reported attending at least four ANC visits and 13 percent at least eight ANC visits. Among these women, IPTp use ranged from 87 percent for the first dose to 48 percent for the third dose.

Family Planning and Reproductive Health

Modern Contraceptive Prevalence Rate (mCPR) in Kenya has steadily increased from 39 percent in 2008-09 to 57 percent in 2022. However, Unmet Need for modern contraceptives and teenage pregnancy rates remain high at 14 percent and 15 percent, respectively, with marked geographical variations. Though nearly all women and men (99%) report knowledge about modern contraceptive methods, this has not translated into high contraceptive prevalence rates, especially among youth and marginalized populations, as persistent gaps remain in individual self-efficacy and positive social norms to use family planning (FP), negotiate safe sex, and reduce intimate partner violence.

Utilization of family planning and reproductive health services is influenced by a range of issues including social-cultural beliefs and practices, gender norms (including intra household decision making), knowledge and attitudes, and access to services. Supply-side interventions are not sufficient alone to fully improve Kenyan sexual and reproductive

4 https://malariabehaviorsurvey.org/ https://malariabehaviorsurvey.org/ https://malariabehaviorsurvey.org/ health at an individual or population level. Improving family planning and reproductive health in Kenya requires consistent SBC interventions/strategies that help address gender inequality, harmful gender norms, intimate partner and gender-based violence, and create a supportive enabling environment for family planning and reproductive health promotion, demand and utilization.

Maternal, Newborn and Child Health

Kenya has made significant strides in maternal, newborn and child health (MNCH) indicators. The Kenya demographic health survey (KDHS 2020) showed a significant increase in live births assisted by skilled providers, from 41 percent in 2003 to 89 percent in 2022, vaccination coverage rate for basic antigens gradually increased from 77 percent in 2008/2009 to 80 percent in 2022, stunting levels decreased from 26 percent to 18 percent between 2014 and 2022. Under-5 mortality also declined from 115 deaths per 1,000 live births in 2003 to 41 deaths per 1,000 live births in 2022. However, there are vast disparities, pointing to inequalities attributed to financial, geographical, educational, and social-cultural factors. The maternal mortality ratio and neonatal mortality rates have also stagnated. Disrespectful care and delay in accessing care is a major contributor to MNCH morbidity and mortality. The World Health Organization (WHO) identifies gender as a key parameter of health. Gender inequalities often result in health risks for women and girls, and addressing these inequalities leads to a better understanding on how unequal power relations contribute to poor health-seeking behaviors and negative health outcomes.

Traditional cultural norms limit children, women, and girls’ access to service delivery. A gender analysis report by the USAID Afya Halisi (Real Health) Activity revealed the perception that men had some level of control over their wives’ bodies especially when bride wealth had been paid. The implication was that women were not expected to complain—even when unwell. They were expected to make extra efforts to serve in the home and to always fulfill their duties as wives and mothers. Women’s limited decision and controlled access to resources contribute to their inability to access services for themselves and their children. There is a need to engage men and women and identify ways to increase women’s influence over decision making concerning their health. Early sexual debut amongst adolescents and youth increases the risk of sexually transmitted infections and early pregnancy, which is associated with school dropout and decreased access to economic opportunities and resources. Adolescent pregnancy increases the risk of maternal mortality and morbidities including complications of unsafe abortion, prolonged labor, delivery, and postnatal period (maternal and infant nutrition).

With regards to under five mortality, pneumonia accounts for 16 percent of all child deaths and is the second biggest killer of children under five years. Healthcare-seeking levels for acute respiratory infections is at 67 percent in Kenya, which is below the recommended 90 percent global coverage. There are various factors that affect health seeking behavior including availability and access of information and services, socio-cultural beliefs, amongst others. With regards to childhood immunization, demand side barriers to immunization include parents' lack of knowledge about childhood vaccinations, fears about vaccine safety, vaccine hesitancy, and lack of transportation. Caregivers may not be aware of the threat of vaccine-preventable illness or that safe and effective vaccines are available against these diseases.

With regards to sepsis, Neonatal healthcare-associated infections (HAI) are associated with increased morbidity, mortality, long hospital stay, and costs. When resources are limited, addressing HAI through infection prevention and control (IPC) requires prioritizing interventions to maximize impact. According to Kenya National Infection Prevention and Control Policy for Health Care Services (2021), functional IPC committees and quality/ Work Improvement Teams at facility level need behavioral change approach targeting HCWs to continuously improve maternal, neonatal and child health outcomes.

Water Sanitation and Hygiene (WASH) and Menstrual Hygiene Management

(MHM)

Kenya has seen improvements in its WASH access rates over recent years, with water services growing at a faster pace than sanitation. According to 2019 data from the Kenya National Bureau of Statistics (KNBS), national rates of open defecation declined from 13.6 percent in 2009 to 7.4 percent in 2019, while the rates of surface water as a drinking source declined from 26.7 percent in 2009 to 24.1 percent in 2019 (KNBS, 2009 and 2019). The 2020 UNICEF and WHO Joint Monitoring Programme (JMP) reports that 61 percent of Kenyans now have access to basic water services, 32 percent have access to sanitation services and 26 percent have access to basic hygiene services. There is evident inequality between rural and urban populations that is further exacerbated by gender inequality.

Women of reproductive age, (from 15 to 49 years-of age) have an additional potential vulnerability as they must manage menstrual periods, and therefore have specific WASH needs. In many social and cultural contexts menstruation is associated with stress, shame and embarrassment, and with taboos that negatively impact and reinforce gender inequities and social exclusion. Every month, women and girls require access to menstrual materials to manage bleeding, private facilities to change menstrual materials, bathing facilities, clean water, toilet paper and/or soap and water to wash and dry themselves, and soak, wash, dry and/or dispose of used materials.

The divide in access between urban and rural areas is especially stark in the area of sanitation. In urban areas, 57 percent and 29 percent of Kenyans have access to safely managed water services and basic water services, respectively, and 51 percent of Kenyans in rural areas have at least basic access to water services. The access rate to at least basic sanitation services is 35 percent in urban areas, and in rural areas, the access rate is a meager two percent (2%). The JMP data do not include informal settlements.

HIV

On a national level, Kenya is moving closer to achieving the 2030 UNAIDS 95-95-95 targets. However, inequities among the various populations persist. For example, among children living with HIV (CLHIV), it is estimated that 74 percent know their status of which only 74 percent are on treatment with viral suppression at 64 percent. High Interruptions in treatment (IIT) and sub-optimal viral suppression among certain segments and in certain counties suggest adherence challenges. In particular, rates of IIT are almost twice as high among adolescents and young people (AYP) as among the generation population. The rate of IIT is highest among men 20-39 years old (Source: President’s Emergency Plan for AIDS Relief (PEPFAR) data). Closing these gaps and inequities will require targeted SBC and innovative applied behavioral science interventions to “move the needle” toward epidemic control and to complement structural interventions such as differentiated service delivery. As one of the first twelve countries to join the Global Alliance to End AIDS in Children by 2030, Kenya has developed a country road map to focus interventions on pregnant and lactating women (PLW), children, and adolescents. Despite an overall reduction in new HIV infections in Kenya, the country continues to have high rates of HIV incidence among some populations and in some geographical regions. The most affected populations include Female Sex Workers (FSWs) with a prevalence estimated at 27 percent and Men who have Sex with Men (MSM) with a prevalence estimated at 28 percent. These key populations face stigma and experience gender-based violence. An analysis of the distribution of new infections showed that most new infections in 2021 were among women compared to men.

Tuberculosis

Kenya has made significant progress in reducing the incidence of tuberculosis (TB) by steadily increasing the number of cases detected and reducing TB over the years. Despite these achievements, the country has not managed to diagnose all people with TB; 32 percent of incident TB cases were missed in 2022. This gap is even bigger among key and vulnerable populations including People living with HIV, children below 15 years and those with Drug Resistant TB. The treatment coverage gap also remains high with only half of those eligible for treatment reached in 2022. According to the prevalence survey of 2016, the majority of people affected by TB included men of the productive age; 25-34 years and women aged above 65 years. Other vulnerable groups for TB include health care workers and people in congregate settings like prisoners and refugees. SBC strategies for TB will promote appropriate health seeking behavior and access to quality care. These are beneficial in increasing case finding for TB among vulnerable populations, improving treatment coverage and enhancing quality of care for favorable outcomes. Ultimately, this will lead to a reduction in the TB incidence and morbidity and mortality related to TB.

Global Health Security

Global Health Security (GHS) focuses on human and animal health and the environment and their interrelationships. SBC strategies in Kenya have been used to contribute to prevention, risk mitigation and response by strengthening risk communication and community engagement (RCCE). These components have been shown to be crucial to addressing the behavioral and social aspects of health risks that precede and follow a health emergency. To maintain the gains made during the COVID-19 response and to address the persisting gaps, SBC approaches must be integrated into the preparedness and response agenda from the outset. A well-coordinated, timely and strategic RCCE strategy and implementation plan can manage people’s expectations during an emergency and assist response efforts. Affected communities need to be engaged, have their concerns understood and addressed, and offered appropriate support to make the required changes. In addition, a priority area is to reduce antimicrobial resistance (AMR) and improve infection prevention control (IPC), thus further elevating the importance of targeting providers (of both animals and people) within GHS.

B. USAID/KEA Health SBC Activities to Date

USAID/KEA has long supported implementation of SBC activities, both through standalone SBC mechanisms and integrated SBC and service delivery mechanisms. Past and current USAID/KEA supported standalone SBC mechanisms include: Agency for All5, Breakthrough ACTION6, and Health Communication and Marketing (HCM) Activity7.

Documents related to these past and current mechanisms may be available on the USAID Development Experience Clearinghouse8 (DEC).

Current integrated SBC and service delivery mechanisms include:

● Malaria: PMI Kinga

● FP and MNCH: Stawisha Pwani, SCOPE/World Relief,Nuru Ya Mtoto, Tumikia

Mtoto, Jamii Tekelezi, USAID 4 The Child,

● WASH: Tujenge Jamii, Fahari Ya Jamii,Boresha Jamii

● Nutrition: Boresha Jamii,AMPATH Uzima, Stawisha Pwani,Tujenge Jamii,Imarisha

Jamii

● HIV: Imarisha Jamii, Fahari Ya Jamii, Tujenge Jamii, Stawisha Pwani,Dumisha

Afya, AMPATH Uzima, Imarisha Jamii, Tujitegemee

● TB: TB ARC II

● GHS: CORE Group Polio Partnership (CGPP), Community Epidemic and Pandemic

Preparedness (CP3), Transformational Strategies for Farm Output Risk Mitigation (TRANSFORM), and Mission Support for Journey to Self Reliance Pivot (MSP).

C. SBC Context in Kenya

Within the Ministry, SBC related activities fall within the Directorate of Health Promotion and Education (DHPE), part of the State Department of Public Health and Professional Standards. DHPE aims to strengthen national health communication and advocacy and empower communities by addressing social determinants of health, promoting positive change, and improving overall well-being. The DHPE has two divisions: a Division of Health Information, Education, and Communication (IEC) and a Division of Health Promotion and Advocacy. The restructuring also included the creation of five sections: policy, capacity strengthening, monitoring and evaluation, IEC material development, and advocacy. Within these sections, the DHPE has identified the following priorities:

● Policy: Finalizing health promotion strategy, finalizing revised national health promotion strategy, and finalizing development of health communication guidelines and RCCE guidelines.

5 https://geh.ucsd.edu/agency-for-all/ 6 https://breakthroughactionandresearch.org/?s=kenya 7 https://2017-2020.usaid.gov/sites/default/files/documents/1860/HCM_PS_Kenya_factsheet_2019.pdf 8 https://dec.usaid.gov/dec/home/Default.aspx https://geh.ucsd.edu/agency-for-all/ https://breakthroughactionandresearch.org/?s=kenya https://2017-2020.usaid.gov/sites/default/files/documents/1860/HCM_PS_Kenya_factsheet_2019.pdf https://dec.usaid.gov/dec/home/Default.aspx

● Capacity Strengthening: Developing behavior change communication training curriculum, RCCE curriculum, and human-centered design training curriculum.

● Monitoring, Evaluation and Learning: Developing a standardized tool for monitoring activity implementation, developing a system for monitoring activity implementation, and implementing monitoring approaches.

● IEC Material Development: Finalizing development IEC material development guidelines, developing an online system for storing and exchanging materials.

● Advocacy: Finalizing development of advocacy guidelines.

Due to a lack of financial and human resources, the DHPE’s capacity to coordinate SBC activities across the MOH is limited. Individual health area programs within the MOH have more financial and human resources for the design, implementation, monitoring, and coordination of SBC activities, especially health area programs supported by the Global Fund.

D. SBC Programming Challenges

Despite decades of investment in SBC across health areas, progress has stalled.

Programmatic challenges that may have impacted progress include siloed implementation (i.e. service delivery and SBC activities often implement alongside each other without meaningful collaboration, little to no coordination within USAID or the MOH), lack of insights or contextual understanding (i.e. a one-size fits all approach is applied from community to community without consideration for the individual, social, and structural factors that influence health behaviors), and limited innovation (i.e. continued implementation of the same communication-based interventions, such as health communication and health promotion which assume health is the main motivation for behavior change, rather than the implementation of evidence-based activities that address the range of individual, social, and structural behavioral factors ).

III. OBJECTIVES AND EXPECTED RESULTS

A. Theory of Change

As illustrated in Figure 1 below, the theory of change for the Activity is IF individual, social, and structural factors that influence priority health behaviors are identified and addressed through SBC interventions, IF the availability and use of evidence for design, implementation, monitoring, evaluation, and learning of SBC interventions is increased and IF GOK systems, structures, and policies to improve coordination, collaboration, and learning are strengthened and IF individual, organizational, and systems level technical capacity to design, implement, and monitor SBC interventions is strengthened THEN individuals (including providers), households, and communities will adopt and maintain the practice of priority health behaviors.

Figure 1: USAID/KEA SBC Activity Theory of Change

B. Results Framework

As shown in Figure 2 below, the Goal of the Activity is as follows:

Figure 2: USAID/KEA SBC Activity Results Framework

To achieve the goal, IRs, and sub-IRs outlined in the results framework above, the Activity will use theory-informed, evidence-based SBC best practice as well as evidence uptake, knowledge management, capacity strengthening, and system strengthening best practices. All of the activities supported by the Activity should reflect the current state of SBC in Kenya as well as GOK and USAID/KEA priorities.

IV. RELATIONSHIP TO USG AND GOK PRIORITIES

A. Alignment with USG Priorities

The Activity is aligned with USAID/KEA’s CDCS 2020-2025. The CDCS places Kenyan citizens in the driver’s seat of their own development with an overarching five-year goal that Kenya’s competitive private sector, resilient communities and civil society organizations, and citizen-responsive public sector better collaborate to drive improvements to well-being and inclusive growth that promotes sustainability. The Activity aligns with CDCS Development Objective 1 which focuses on improving key systems such as health, governance, and markets; and Development Objective 2, which aims to enhance the resilience of vulnerable populations and environments. Similarly, by addressing specific internal, social, and structural factors that influence health outcomes, the Activity will contribute to the increased utilization of health services, improved health-seeking behavior, strengthening stakeholder coordination structures, and the strengthening of community health services which are among the envisioned results in the USAID/KEA Kenya Health Systems Strengthening Project Design Document.

The Activity is also aligned with the U.S. President’s Malaria Initiative Strategy, End Malaria Faster9; the PEPFAR strategy, Fulfilling America’s Promise to End the HIV/AIDS Pandemic by 203010; USAID Global Tuberculosis Strategy 2023-2030 11; and Primary Impact12. The Activity is aligned with USAID’s priorities in family planning13 and GHS14. The Activity should adhere to the guidance outlined in the PMI Technical Guidance15. The Activity is aligned with The 2023 Gender Equality and Women’s Empowerment Policy (Gender Policy)16.

B. Alignment with GOK Priorities

The Activity is aligned with and contributes to the following GOK strategy and guidance documents: Kenya Health Sector Strategic Plan 2018–2023; Kenya Health Policy Framework 2012-2030; MOH Health Promotion Strategy 2023-2028; Kenya AIDS Strategic Framework II 2020/2021-2024/2025; Kenya AIDS Strategic Framework II 2020/2021-2024/2025 Communication Strategy; HIV and STI Surveillance Strategy 2020-

9 https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2021/10/10.04Final_USAID_PMI_Report_50851.pdf 10 https://www.state.gov/pepfar-five-year-strategy-2022 11 https://www.usaid.gov/global-health/health-areas/tuberculosis/resources/publications/usaid-global-tuberculosis-strategy-2023- 12 https://www.usaid.gov/global-health/health-systems-innovation/health-systems-strengthening/primary-health-care 13 https://www.usaid.gov/global-health/health-areas/family-planning 14 https://www.usaid.gov/global-health/health-areas/global-health-security 15 https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2023/02/PMI-FY-2024-Technical-Guidance.pdf 16 https://www.usaid.gov/sites/default/files/2023-03/2023_Gender%20Policy_508.pdf https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2021/10/10.04Final_USAID_PMI_Report_50851.pdf https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2021/10/10.04Final_USAID_PMI_Report_50851.pdf https://www.state.gov/pepfar-five-year-strategy-2022/#:%7E:text=Fulfilling%20America%27s%20Promise%20to%20End,public%20health%20threat%20by%202030 https://www.state.gov/pepfar-five-year-strategy-2022/#:%7E:text=Fulfilling%20America%27s%20Promise%20to%20End,public%20health%20threat%20by%202030 https://www.usaid.gov/global-health/health-areas/tuberculosis/resources/publications/usaid-global-tuberculosis-strategy-2023-2030 https://www.usaid.gov/global-health/health-systems-innovation/health-systems-strengthening/primary-health-care#:%7E:text=USAID%20Launches%20Primary%20Impact,Kenya%2C%20Malawi%2C%20and%20Nigeria https://www.usaid.gov/global-health/health-areas/family-planning https://www.usaid.gov/global-health/health-areas/global-health-security https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2023/02/PMI-FY-2024-Technical-Guidance.pdf https://www.usaid.gov/sites/default/files/2023-03/2023_Gender%20Policy_508.pdf https://www.usaid.gov/sites/default/files/2023-03/2023_Gender%20Policy_508.pdf https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2021/10/10.04Final_USAID_PMI_Report_50851.pdf https://www.state.gov/pepfar-five-year-strategy-2022 https://www.usaid.gov/global-health/health-areas/tuberculosis/resources/publications/usaid-global-tuberculosis-strategy-2023-2030 https://www.usaid.gov/global-health/health-areas/tuberculosis/resources/publications/usaid-global-tuberculosis-strategy-2023-2030 https://www.usaid.gov/global-health/health-systems-innovation/health-systems-strengthening/primary-health-care https://www.usaid.gov/global-health/health-areas/family-planning https://www.usaid.gov/global-health/health-areas/global-health-security https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2023/02/PMI-FY-2024-Technical-Guidance.pdf https://www.usaid.gov/sites/default/files/2023-03/2023_Gender%20Policy_508.pdf

2024; HIV Drug Resistance Testing Strategy 2020-2024; Kenya HIV Prevention Revolution Roadmap; Kenya National Action Plan for Health Security (NAPHS) 2019-2023; Kenya Malaria Social and Behavior Change Strategy 2022-2027; Kenya Malaria Behavior Survey Report 2022; and IHR/JEE Version 3.0, section R5.

In addition, the SBC Activity is aligned to the DHPE and its expected results within the next five years. These include the establishment of health promotion policies, increased awareness and adoption of healthy behaviors, enhanced stakeholder and community engagement, improved monitoring systems, and increased awareness of social determinants of health. The expected impact includes enhanced multi-sectoral approaches in health, reduced spread of diseases, increased demand for preventive health services, empowered communities to address health challenges, and reduced health inequalities among different populations. These efforts aim to empower communities and address health challenges in a comprehensive and equitable manner.

V. GUIDING PRINCIPLES

A. Integration

As previously mentioned, USAID/KEA anticipates that the Activity will include buy-ins from multiple health areas, including malaria, HIV, family planning and reproductive health, MNCH, TB, and GHS. Where logistically possible and technically feasible, the Activity is encouraged to explore the design and implementation of integrated SBC interventions.

SBC integration can be carried out by segmenting priority populations and by designing SBC interventions according to life stage (e.g., adolescents and young adults), addressing shared behavioral determinants (e.g., gender norms), or leveraging gateway behaviors (e.g., ANC visits) to name a few commonly used approaches to SBC integration. An additional approach to integration may be to integrate SBC interventions for priority health behaviors into other sectors including education or agriculture. However, where it is not logistically possible or technically feasible, SBC interventions focused on a single health area are acceptable.

B. Coordination with Service Delivery

SBC must be coordinated with service delivery programs. The Activity must work collaboratively with USAID-supported and GOK service delivery activities where there is geographic overlap. The Circle of Care17 model provides a useful framework for the role of SBC before, during and after services are provided. As described below, the Activity’s engagement with USAID-supported service delivery partners will depend on the health area and geographic focus area.

C. Best Practice SBC

USAID/KEA embraces and insists on the use of a theory-informed and evidence-based approach to determine the SBC interventions that are best suited to address the internal, 17 https://breakthroughactionandresearch.org/circle-of-care-model/ https://breakthroughactionandresearch.org/circle-of-care-model/…