NOFO 72062125RFA0001.pdf

NOFO No. 72062125RFA00001 USAID Thamini Afya (Value Your Health)

Issue Date: November 7, 2024 Deadline for Questions: November 20, 2024; 17:00 EAT Closing Date: December 9, 2024 Closing Time: 17:00 EAT

Subject: Notice of Funding Opportunity Number (NOFO): 72062125RFA00001

Program Title: USAID Thamini Afya (Value your Health)

Federal Assistance Listing Number: 98.001

Greetings, The United States Agency for International Development (USAID) is seeking applications for a cooperative agreement from qualified entities to implement USAID/Tanzania activity entitled “USAID Thamini Afya (Value Your Health)”. Eligibility for this award is not restricted, see Section B of this NOFO for eligibility requirements.

Subject to the availability of funds and continued relevance of the Activity to USAID’s programming, USAID/Tanzania intends to provide up to $16,450,000.00 in total funds to be allocated over a 5-year period to the applicant 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.

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

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 usaidtzco@usaid.gov with the point(s) of contact identified in Section A.4 copied. 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 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, Ashley Burgin Agreement Officer mailto:usaidtzco@usaid.gov

Table of Contents

SECTION A: BASIC INFORMATION

SECTION B: ELIGIBILITY

SECTION C: PROJECT DESCRIPTION

SECTION D: APPLICATION CONTENT AND FORMAT

SECTION E: SUBMISSION REQUIREMENTS AND DEADLINES

SECTION F: APPLICATION REVIEW INFORMATION

SECTION G: AWARD NOTICES

SECTION H: POST-AWARD REQUIREMENTS AND ADMINISTRATION

SECTION I: OTHER INFORMATION

ANNEX 1 - SUMMARY BUDGET TEMPLATE

ANNEX 2 - STANDARD PROVISIONS

ANNEX 3 - ABBREVIATIONS AND ACRONYMS

SECTION A: BASIC INFORMATION

A.1 Executive Summary

The goal of the USAID Thamini Afya (Value your Health) Activity (“Activity”) is to increase the practice of desired health behaviors by individuals (including healthcare providers), households, and communities by (IR 1) strengthening SBC capacity and coordination of SBC actors; (IR 2) designing theory-informed, evidence-based SBC interventions; and (IR 3) implementing, monitoring, and evaluating SBC interventions nationally and sub-nationally.

To achieve IR 1, this Activity will strengthen the capacity of Government of Tanzania (GOT) counterparts at the national level, the Ministry of Health (MOH)/Health Promotion Section (HPS), Health Programs, and President’s Office-Regional and Local Government (PO-RALG), and at the sub-national levels (regional and district levels) to better manage and sustain social and behavior change (SBC) interventions. This Activity will improve SBC coordination systems by ensuring that clear roles and responsibilities of each SBC actor are well defined and strengthen the capacity of GOT actors in managing the interventions. The Activity will also strengthen the SBC technical capacity of the U.S. Government (USG) service delivery partners that support sub-national implementation of SBC interventions at the community and facility levels. To achieve IR 2, this Activity will support design of SBC interventions using best practices, revamping current approved SBC interventions supported by GOT, and ensuring that approved interventions are responsive to the needs of the community and driven by data and evidence. To achieve IR 3, the Activity will implement, monitor and evaluate SBC interventions at the national and sub-national level (as needed).

All SBC interventions in Tanzania must be guided by relevant GOT policies. The Activity will be aligned with the U.S. President’s Malaria Initiative Strategy, End Malaria Faster, the PEPFAR 5-year strategy, USAID’s priorities in family planning and Global Health Security (GHS) and other relevant U.S policies and strategies. To ensure adequate coordination of SBC activities, GOT will thoroughly review, approve and keep an inventory of all SBC interventions and tools developed under this project before they are disseminated at the national and sub-national levels. This Activity will work closely with other donors and local actors to avoid redundancies or duplication of SBC interventions by defining roles and responsibilities of each actor and ensuring that SBC interventions are well harmonized. This can be achieved by engaging all responsible stakeholders from the government, donors, service delivery partners who are implementing at the community level, and private sector, including media. The Activity will engage and directly involve USG service delivery (USAID and interagency) partners implementing SBC interventions at the sub national/ community level to ensure that designed SBC interventions (which are done at national level) are data driven through incorporating information on the remaining gaps from communities. This Activity will be responsible for collecting, monitoring, and analyzing data from the service delivery partners implementation at the community to inform decisions to be made at national level.

USAID/Tanzania anticipates that this Activity will include a range of health areas such as malaria, maternal health, newborn and child health, global health security, family planning, tuberculosis, emerging diseases, and HIV. It may also address cross-cutting health issues such as WASH and nutrition and others as deemed appropriate.

To ensure that this Activity is achieving the desired results and able to demonstrate meaningful progress, USAID/Tanzania expects at a minimum the following essential outcome/impact level indicators to be monitored:

● Increase in GOT capacity to coordinate, finance, manage and track SBC activities as measured by the percentage increase in GOT-managed SBC implementation, monitoring, and evaluation activities.

● Percentage increase or decrease in the practice of targeted health behaviors and behavioral determinants among people reached with SBC interventions.

● Improved awareness of antimicrobial resistance (AMR) and behavior change among health workers and the general public.

A.2 Estimate of Funds Available and Number of Awards Contemplated

USAID intends to award a 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 $16,450,000 in total USAID funding over a five-year period.

A.3 Start Date and Period of Performance for Federal Awards

The anticipated period of performance is five (5) years. The estimated start date will be March 2025.

A.4 Agency Point of Contact

Gloria Matau Acquisition & Assistance Specialist Email: gmatau@usaid.gov USAID/Tanzania 686 Old Bagamoyo Road, Msasani P. O. Box 9130 Dar es Salaam, Tanzania and

Ashley Burgin Agreement Officer Email: aburgin@usaid.gov USAID/Tanzania mailto:gmatau@usaid.gov mailto:aburgin@usaid.gov

686 Old Bagamoyo Road, Msasani P. O. Box 9130 Dar es Salaam, Tanzania

A.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

A.6 Authorized Geographic Code

The geographic code for the procurement of commodities and services under this program is Code 935 (any area or country including the recipient country but excluding any country that is a prohibited source). 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.

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

SECTION B: ELIGIBILITY

B.1 Eligible Applicants

Eligibility for this NOFO is not restricted.

All U.S. and non-U.S. public, private, for-profit, and nonprofit organizations, as well as institutions of higher education, parochial, and other non-governmental organizations are eligible to submit an application. Further, the organization must be a legally recognized entity under applicable law.

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

Each applicant organization is limited to one application submission as the prime applicant.

There is no limitation on being included as a potential sub-awardee. USAID discourages the use of exclusive teaming arrangements.

B.2 Cost Sharing

Cost Sharing is not required for this Activity.

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SECTION C: PROJECT 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.

C.1 Goal

The Activity will support individuals (including healthcare providers), households, and communities to adopt and maintain the practice of desired health behaviors by (IR 1) strengthening SBC capacity and coordination; (IR 2) designing theory-informed, evidence-based SBC interventions; and (IR 3) implementing, monitoring and evaluating SBC interventions nationally and sub-nationally.

The Activity will contribute to the achievement of the development objectives outlined in the USAID/Tanzania Country Development Cooperation Strategy 2020-2025 (CDCS)1, as well as the USAID Bureau for Global Health’s strategic priorities of preventing child and maternal deaths;

achieving and sustaining epidemic control; and combating infectious diseases2.

C.2 Background and Development Challenges

Across health areas, success depends on human behavior. The ability, opportunity, and motivation of individuals (including healthcare 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 SBC interventions can support populations to adopt and sustain priority behaviors by addressing the 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”.

a. SBC Challenges

Tanzania has made remarkable progress in the expansion of primary health care, with services reaching most communities and households in both urban and rural areas. However, despite such significant progress, Tanzania still suffers the double burden of communicable and non-communicable diseases. Early healthcare seeking behaviors at the individual, household and community levels remains a challenge due to individual behaviors, social cultural norms, 3 https://thinkbigonline.org/action/document/download?document_id=416

2 https://www.usaid.gov/global-health

1 https://www.usaid.gov/tanzania/country-development-cooperation-strategy https://www.usaid.gov/tanzania/country-development-cooperation-strategy https://www.usaid.gov/global-health https://www.usaid.gov/global-health https://thinkbigonline.org/action/document/download?document_id=416 provider’s attitudes and community engagement. Healthcare providers biases, norms and attitudes continue to influence a patient’s sustained uptake of services. This often unwelcoming atmosphere and poor communication between providers and patients compounded with barriers such as cultural and traditional factors lead to low utilization of health services.

Appropriate, well coordinated, designed, implemented, monitored and evaluated SBC interventions targeting individual behaviors, social cultural norms, providers’ attitudes and community engagement are critical to improving health behaviors towards increase in health services uptake. Over the years, coordination of SBC interventions has remained a key challenge.

Within the public sector, the Health Promotion Section (HPS), which falls under the Ministry of Health (MOH), is responsible for serving as the main national-level government entity overseeing and ensuring the quality of all SBC interventions for health. The government Health Programs under the MOH such as National Malaria Program (NMCP), National TB and Leprosy Program (NTLP), National AIDS, STIs and Hepatitis Control Program (NASHCoP), Reproductive and Child Health Section (RCHS) should be working closely with HPS on SBC design, guidelines and policy development, and monitor implementation of SBC interventions. However, some of the Health Programs often implement their own SBC interventions without working through HPS leading to inefficiencies and inconsistent messaging. Additionally, lack of clear roles and division of responsibilities vertically between national entities, such as MOH, Health Programs, and PO-RALG, and sub-national government entities, such as local government authorities (LGAs) and Regional and Council Health Management Teams (R/CHMTs), further add to fragmentation and create redundancy in efforts.

Additional SBC coordination challenges exist when trying to work with a multitude of stakeholders that involve non-governmental actors such as civil society and the private sector.

The expertise and interests of the government, private sector, and civil society must be taken into account in determining who plays what role. Actors from these sectors must work together to build and operationalize a sustainable SBC framework. Although government stewardship of the process is critical, the private sector must be incentivized and be given the latitude to play a more significant role in creating a sustainable outcome. Private media houses, printers and publishers, professional organizations, community-based organizations, faith-based organizations, and civil society organizations will need to collaborate and coordinate interventions with the MOH and other relevant ministries.

Limited technical and management capacity of the MOH/HPS, PO-RALG, and Health Programs hinder SBC interventions at all levels. Although there have been improvements in recent years such as the design of integrated NAWEZA and SITETEREKI platforms and the FURAHA YANGU campaign, some government health programs still rely on outdated and sub-optimal approaches such as Information, Education and Communication (IEC). Designing targeted and effective SBC based on evidence remains a challenge with limited capacity to monitor and evaluate interventions.

In sum, the existing SBC key challenges in Tanzania include: (1) lack of strong coordination of SBC interventions at the national, regional and local government levels, including across sectors; (2) lack of clear roles and responsibilities of SBC actors; (3) limited GOT technical and management capacity to manage SBC interventions at all levels; (4) lack of capacity to design theory-informed, evidence-based SBC interventions; (5) lack of capacity to implement, monitor and evaluate SBC interventions at different levels; (6) limited engagement of the private sector; and, (7) inadequate use of data for decision making.

These challenges impact the quality, efficiency, effectiveness, and sustainability of SBC interventions and limit synergies of SBC interventions implemented by the various health programs, such as malaria, HIV/AIDS, TB, among others. A well coordinated SBC activity is needed to assure quality SBC interventions align with national strategies and program standards. In this regard, this Activity will play a pivotal role in strengthening systems and processes that improve quality and enhance coordination of SBC activities at national and subnational levels, across different disease areas.

b. Health Sector Challenges

Global Health Security

Global Health Security (GHS) focuses on building a country’s capacity to prevent, detect, and respond to emerging infectious disease threats with a One Health lens - at the intersection of human, animal and environmental health. SBC strategies have been used in disease prevention, risk mitigation and response to strengthen risk communication and community engagement (RCCE). Disease prevention and risk communication have been critical for addressing the behavioral and social aspects of health risks that precede and follow a public 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.

In addition, a priority area is to reduce antimicrobial resistance (AMR) and improve infection prevention control (IPC), thus further elevating the importance of targeting healthcare providers (of both animals and people) within GHS. In clinical settings in Tanzania, the prevalence of multidrug-resistant (MDR) bacteria ranges from 25% to 50%. About two-thirds of isolates from wound infections at Muhimbili National Hospital were found to be MDR. Limited sporadic studies conducted to assess hand hygiene standards among healthcare providers revealed low compliance ranging between 6.9% and 24%, whereas compliance in using alcohol rub was 41%.

Both AMR and the spread of infections are rooted in a lack of awareness and harmful practices, so RCCE can play a key role in helping to mitigate their impacts.

Family Planning and Reproductive Health

Modern Contraceptive Prevalence Rate (mCPR) in Tanzania has slightly decreased from 32 percent in 2015-16 (2015-2016 Tanzania Demographic and Health Survey and Malaria Indicators https://dhsprogram.com/pubs/pdf/FR321/FR321.pdf

Survey [2015-2016 TDHS-MIS])4 to 31 percent in 2022. More married women (32%) in Tanzania mainland use modern methods of family planning than their counterparts in Zanzibar (17%) (2022 TDHS-MIS)5. According to the 2022 TDHS-MIS, the unmet need for family planning remains high at 21 percent, with marked geographical variations. Though nearly all married women and men aged 15-49 years (98%) report having knowledge about modern contraceptive methods, this has not translated into a high rate of contraceptive use, especially among all women where we see a contraceptive prevalence of 31 percent. Among married women, the contraceptive prevalence is 38 percent and among sexually active unmarried women, it is at 45 percent (2022 TDHS-MIS). Demand for family planning among currently married women aged 15–49 in Tanzania has slightly decreased from 61 percent in 2015–16 (2015-2016 TDHS-MIS) to 59 percent in 2022 (2022 TDHS-MIS). Utilization of family planning and reproductive health services is influenced by a range of factors including social-cultural beliefs and practices, gender norms and dynamics (including intra household decision making), gender inequality, healthcare provider biases, intimate partner and gender-based violence, knowledge and attitudes, and access to services.

Improving family planning and reproductive health in Tanzania requires SBC interventions that address these factors and create an enabling environment for family planning and reproductive health promotion, demand creation and uptake.

HIV

The UNAIDS 95-95-95 targets for 2025 call for 95 percent of all people living with HIV to be aware of their HIV status, 95 percent of those aware of their status to be on antiretroviral treatment (ART), and 95 percent of those on ART to achieve viral load suppression (VLS). On a national level, Tanzania has met the second of the three targets ahead of 2025, demonstrating access to and uptake of robust treatment programs among those who are aware of their HIV-positive status.

Tanzania has made remarkable gains since the 2016-2017 Tanzania HIV Impact Survey (2016-2017 THIS)6, in which progress toward UNAIDS 95-95-95 targets was at 61 percent, 94 percent, and 87 percent. Notably, the 2022-2023 Tanzania HIV Impact Survey (2022-2023 THIS)7 estimated that among people aged 15 years and older living with HIV in Tanzania, only 83 percent are aware of their status while 98 percent of those who are aware of their HIV status are on ART, and 94 percent of those on ART are virologically suppressed. However, disparities exist by sex and across age bands and regions. Among adults who know their HIV status, 85 percent are women and 78 percent are men (2022-2023 THIS). The 2022-2023 THIS also showed that viral load suppression among all adults living with HIV was 78 percent (81 percent among women compared to 72 percent among men). Younger adults were less likely to achieve viral load suppression than older adults.

7 https://phia.icap.columbia.edu/wp-content/uploads/2023/12/THIS-SS_5DEC2023.pdf

6https://phia.icap.columbia.edu/wp-content/uploads/2020/02/FINAL_THIS-2016-2017_Final-Report__06.21.19_for-web_TS.pdf

5 https://dhsprogram.com/pubs/pdf/PR144/PPR144.pdf

4 https://dhsprogram.com/pubs/pdf/FR321/FR321.pdf https://dhsprogram.com/pubs/pdf/FR321/FR321.pdf https://dhsprogram.com/pubs/pdf/PR144/PPR144.pdf https://phia.icap.columbia.edu/wp-content/uploads/2020/02/FINAL_THIS-2016-2017_Final-Report__06.21.19_for-web_TS.pdf https://phia.icap.columbia.edu/wp-content/uploads/2020/02/FINAL_THIS-2016-2017_Final-Report__06.21.19_for-web_TS.pdf https://phia.icap.columbia.edu/wp-content/uploads/2023/12/THIS-SS_5DEC2023.pdf

There are also marked variations in HIV prevalence by age, sex, and region, with a higher prevalence among women and in certain regions of mainland Tanzania. HIV prevalence is below one percent in all the regions of Zanzibar. Enhanced case finding by addressing behavioral and structural barriers among populations who are unaware of their HIV-positive status or outside of the care system remains an important program intervention to address gaps in the first 95.

The 2022 TDHS results show that less than half of women and men (42% and 38%, respectively) aged 15–24 have comprehensive knowledge of HIV prevention. Closing these gaps and others will require addressing these factors and others such as social norms and stigma through targeted SBC and innovative applied behavioral science interventions. These approaches will help to “move the needle” toward epidemic control and to complement structural interventions such as differentiated service delivery.8

In Tanzania, cervical cancer ranks first in both incidence and mortality, accounting for 24.2% of new cancer cases and 23% of cancer-related deaths in 2022 (Global Cancer Observatory, 2022).

More than 99% of cases of cervical cancer are caused by infection with human papillomavirus (HPV); and the HPV vaccine can prevent up to 90% of all cervical cancer cases. Women living with HIV (WLHIV) are at higher risk of persistent HPV infection and are six times more likely to develop precancerous lesions that advance to cervical cancer. As part of USG’s Go Further Ending AIDS and Cervical Cancer, SBC approaches should be used in improving demand creation for screening and testing of precancerous lesions among women living with HIV (WLHIV) aged 18 and above.

Malaria

Human behavior, including use of insecticide treated nets (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 by healthcare providers, is critical to achieving malaria control and elimination objectives. In Tanzania, the prevalence of these behaviors among priority populations varies, as do the individual, social, and structural factors that influence these behaviors. The 2022 TDHS-MIS indicated that on the mainland, 64% of children and 66% of pregnant women slept under an ITN the night before the survey, care was sought for 78% of children under five with fever, 65% of women attended the recommended four ANC visits during their last pregnancy, and 60% of women received two or more doses of IPTp during their last pregnancy in the two years preceding the survey against the recommended standard by NMCP which is 85% by 2025. In Zanzibar, the 2022 TDHS-MIS indicated that 66% of children and 66% of pregnant women slept under an ITN the night before the survey, care was sought for 81% of children under five with fever, and 79% of women attended four ANC visits during their last pregnancy. In 2022, the U.S. President’s Malaria Initiative9 supported the implementation of the Malaria Behavior Survey (MBS)10 to better understand the factors that influence the practice of these behaviors. According to the mainland MBS, the following behavioral factors were associated with consistent ITN use: perceived self-efficacy, favorable

10 https://malariabehaviorsurvey.org/

9 www.pmi.gov

8 2022-2023 THIS

https://dhsprogram.com/pubs/pdf/PR144/PPR144.pdf https://www.state.gov/partnership-to-end-aids-and-cervical-cancer/ https://www.state.gov/partnership-to-end-aids-and-cervical-cancer/ https://www.pmi.gov/ https://malariabehaviorsurvey.org/ attitudes towards net use (aOR 2.98, p-value <0.0001), and supportive descriptive community norms (aOR 2.26, p-value <0.0001). Similar results were found in Zanzibar: perceived self-efficacy (aOR 6.09), favorable attitudes toward net use (aOR 3.36), supportive descriptive community norms (aOR 2.15), favorable attitudes (aOR 1.67), and perceived susceptibility (aOR 1.43) were associated with consistent ITN use. The survey report for mainland Tanzania11 and survey report for Zanzibar12 include similar data for factors influencing other priority malaria behaviors.

Maternal, Newborn, and Child Health

Tanzania has made significant strides in maternal and child health (MCH) indicators. The percentage of women who had the recommended four or more ANC visits increased from 38 percent in the 2010 TDHS to 48 percent in the 2015–16 TDHS-MIS and 65 percent in the 2022 TDHS-MIS. The percentage of women who sought ANC during the first trimester also increased from 22 percent in the 2015–16 TDHS-MIS to 34 percent in the 2022 TDHS-MIS. Over the same period, infant mortality declined from 43 to 33 deaths per 1,000 live births, while neonatal mortality remained basically unchanged, decreasing slightly from 25 deaths per 1,000 live births to 24 in 2022 (TDHS)so much efforts are needed on newborn health

However, the 2022 TDHS-MIS showed a decrease in the percentage of women who received ANC from a skilled provider for the most recent live birth. Moreover, there are vast disparities, pointing to inequalities attributed to financial, geographical, educational, and social-cultural factors. Urban areas are expected to have lower early childhood mortality than rural areas due to better education, living conditions, and access to health facilities with well-trained healthcare providers. Contrary to that expectation, neonatal, infant, and under-5 mortality rates are higher among children in urban areas than among those in rural areas.

Disrespectful care and delays in accessing care are major contributors 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 using SBC approaches help better understand how unequal power relations contribute to poor health-seeking behaviors and negative health outcomes.

Tuberculosis

Tanzania has experienced a 17% reduction in TB incidence from 2018 to 2022 (Global Tuberculosis Report 2023). This is attributable, partly, to a significant decrease in the incidence of TB among people living with HIV as a result of increased access to ART with coverage above 80% among all people living with HIV 15 years and above (THIS 2022-2023). Geographical variations in TB notifications rates exist due to regional population size, the magnitude of attributable factors (HIV, poverty and malnutrition, smoking, Diabetic Mellitus and alcohol abuse), and access and

12https://malariabehaviorsurvey.org/wp-content/uploads/2022/11/Zanzibar-Low-Transmission-MBS-Report-En.pdf

11https://malariabehaviorsurvey.org/wp-content/uploads/2024/01/mainland-Tanzania-MBS-Report-2023Dec-INTERI M.pdf https://malariabehaviorsurvey.org/wp-content/uploads/2024/01/Mainland-Tanzania-MBS-Report-2023Dec-INTERIM.pdf https://malariabehaviorsurvey.org/wp-content/uploads/2022/11/Zanzibar-Low-Transmission-MBS-Report-En.pdf https://malariabehaviorsurvey.org/wp-content/uploads/2022/11/Zanzibar-Low-Transmission-MBS-Report-En.pdf https://iris.who.int/bitstream/handle/10665/373828/9789240083851-eng.pdf?sequence=1 https://iris.who.int/bitstream/handle/10665/373828/9789240083851-eng.pdf?sequence=1 https://www.nbs.go.tz/nbs/takwimu/THIS2022-2023/THIS2022-2023_Summary_Sheet.pdf utilization of health services. In 2022, Dar es Salaam and Dodoma (urban areas/cities); Arusha, Geita, Shinyanga, Manyara, Singida and Mara (large population of artisanal miners) had the highest TB notifications. Program data in 2022 shows that the highest TB notifications are among the age groups 25-34 (18%) and 35-44 (16.6%) years. Similarly, 1.8% and 1.2% of the TB notifications in 2022 were among miners and prisoners respectively. Males continue to top the proportion of TB notifications in 2022 at 59% of all the notifications. TB treatment success rates have been sustained at above 90% since 2018. However, two regions (Mbeya and Tabora) accounted for more than 5% TB deaths in the 2021 cohort (unpublished TB routine program data).

C.3 Relationship to USG and GOT priorities

c. Alignment with USG Priorities

This Activity is critical to the achievement of USAID/Tanzania’s Country Development Cooperation Strategy (CDCS) for 2020 - 202513. In particular, this Activity, through Development Objective (DO) 3, will strengthen the capacity of national level government counterparts including MOH, PO-RALG, government Health Programs and sub-national governments at the regional and district levels to lead sustainable SBC interventions by improving coordination and define clear roles and responsibilities of all SBC actors in the SBC process. This Activity will also strengthen the capacity of service delivery partners implementing SBC activities at sub-national level.

The Activity will also support DO2 “Empowerment, productivity and engagement of Tanzanians aged 15 to 35 increased“ by improving their health, which will enable young Tanzanians to live healthier lives, and thus spend less time and money on health care expenses. Through expanding and developing the skills of healthcare workers, and using evidence-based approaches to increase access, quality, and use of health services, young Tanzanians will be empowered to take ownership of their wellbeing. The Activity will also support DO1 “Foundational Skills of Children Below Age 15”. The availability of quality health services is not always enough to improve access to quality care; changing the health-seeking behaviors of individuals and communities, as well as the norms that underpin those behaviors is necessary. As such, improved SBC strategies are essential for increasing optimal health practices, demand for services and products, and ultimately, increase the use of services. Interventions will equip communities, faith leaders, influential people, families, and healthcare workers with the right skills and information to maximize access to and use of quality pediatric services that improve the health of children.

The Activity is also aligned with the U.S. President’s Malaria Initiative Strategy, End Malaria Faster; the PEPFAR strategy, Fulfilling America’s Promise to End the HIV/AIDS Pandemic by 203014;

Go Further Partnership to End AIDS and Cervical Cancer, USAID Global Tuberculosis Strategy

14 https://www.state.gov/pepfar-five-year-strategy-2022

13 https://www.usaid.gov/tanzania/country-development-cooperation-strategy https://www.usaid.gov/tanzania/country-development-cooperation-strategy https://www.usaid.gov/tanzania/country-development-cooperation-strategy 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/#:~:text=Fulfilling%20America%27s%20Promise%20to%20End,public%20health%20threat%20by%202030 https://www.state.gov/partnership-to-end-aids-and-cervical-cancer/ https://www.state.gov/partnership-to-end-aids-and-cervical-cancer/ https://www.usaid.gov/global-health/health-areas/tuberculosis/resources/publications/usaid-global-tuberculosis-strategy-2023-2030 https://www.usaid.gov/tanzania/country-development-cooperation-strategy

2023-2030 15; and Primary Impact16. The Activity is aligned with USAID’s priorities in family planning17 and GHS18. The Activity should adhere to the guidance outlined in the PMI Technical Guidance19 . The Activity is aligned with The 2023 Gender Equality and Women’s Empowerment Policy (Gender Policy)20.

d. Alignment with USAID/Tanzania Investments

This Activity should build on accomplishments and lessons from previous and ongoing USAID/ Tanzania investments in SBC, which include the following:

● Breakthrough ACTION Tanzania is a three-year (2022-early 2025) activity that has provided technical assistance to the GOT (MOH/HPS, Health Programs, and PORALG) to improve the policy and implementation framework for SBC. It also supported design of all SBC interventions, and implementation, and monitoring at the national and sub-national level (regions and districts). The activity has provided training to build the technical capacity of staff from HPS, PORALG and LGA. The activity has also focused on integrating SBC approaches across health areas such as reproductive health/family planning, MNCH (including nutrition), HIV, malaria, tuberculosis (TB), and other infectious diseases as needed.

● USAID Tulonge Afya (Let’s Talk Health) was a five-year (2017-2022) activity that catalyzed opportunities for Tanzanians to improve their health status by transforming socio-cultural norms and supporting the adoption of healthier behaviors. USAID Tulonge Afya identified the drivers of health behaviors and leveraged social, and behavior change communication (SBCC) and other mutually reinforcing approaches to improve the ability of individuals to practice the priority behaviors. It also initiated community platforms and structures to begin to coordinate and implement SBCC interventions.

USAID/Tanzania has also invested in a number of service delivery mechanisms to support implementation of SBC activities at the community and facility level. This Activity should provide technical assistance, as needed, to current USG service delivery mechanisms and may need to collaborate with other USG activities working in non-health sectors to reach the desired beneficiaries.

Current mechanisms include, but are not limited to:

● USAID Afya Yangu (My Health) Northern (2021-2026).

● USAID Afya Yangu (My Health) Southern (2021-2026).

20 https://www.usaid.gov/sites/default/files/2023-03/2023_Gender%20Policy_508.pdf

19 https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2023/02/PMI-FY-2024-Technical-Guidance.pdf

18 https://www.usaid.gov/global-health/health-areas/global-health-security

17 https://www.usaid.gov/global-health/health-areas/family-planning

16https://www.usaid.gov/global-health/health-systems-innovation/health-systems-strengthening/primary-health-car e

15https://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#:~: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/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://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

● PMI Shinda (Defeat) Malaria (2022-2027).

● PMI Dhibiti (Control) Malaria (2022-2027).

● USAID Afya Yangu - Mama na Mtoto (Mother and Child) (2022-2027).

● USAID Uzazi Staha (Respectful Maternal Care) (2020-2025).

● Meeting Targets and Maintaining Epidemic Control (EpiC)

● USAID Afya Shirikishi (Participatory Health) (2020-2025)

Deliverables from previous USAID/Tanzania SBC investments and service delivery mechanisms are available on the USAID Development Experience Clearinghouse21.

e. Link with GOT Priorities

USAID/Tanzania expects this Activity to be consistent with the following mainland MOH and Zanzibar MOH documents:

a. Health Sector Strategic Plan V (HSSP V) 2021 -202622

b. National Malaria Strategic Plan 2020-202523

c. Zanzibar Health Sector Strategic Plan IV

d. National Social and Behavior Change & Advocacy Strategy for Malaria Interventions

2021-202524

e. Zanzibar Malaria Social and Behavior Change Strategy (2024-2029)

f. National Tuberculosis Strategic Plan VI 2020-202525

g. Tanzania National Family Planning Costed Implementation Plan (2019-2023)26

h. The National HIV and AIDS Advocacy and Communication Strategy

i. National One Health Strategic Plan 2022-2027

j. National Action Plan for AMR 2023-2028

k. National Action Plan for Health Security 2017-2021 (currently under revision)

C.4 Results

a) Theory of Change

As illustrated in Figure 1 below, the theory of change for the Activity is IF SBC interventions are well coordinated and capacity of SBC actors are strengthened, IF SBC interventions designed are evidence-based and address the factors that influence desired health behaviors, IF SBC interventions are implemented well and at scale, and IF SBC data are collected, analyzed and

26https://tciurbanhealth.org/wp-content/uploads/2019/07/National-Family-Planning-Costed-Implementation-Plan-201 9-2023-INSIDE-%E2%80%A2-F....pdf

25 https://ntlp.go.tz/site/assets/files/1080/national_tuberculosis_and_leprosy_strategic_plan_vi_final_version.pdf 24 www.nmcp.go.tz/storage/app/uploads/public/643/90b/da8/64390bda839ac599662656.pdf 23 http://api-hidl.afya.go.tz/uploads/library-documents/1641210939-jH9mKCtz.pdf 22 https://extranet.who.int/countryplanningcycles/planning-cycle-files/health-sector-strategic-plan-hssp-v-2021-2026 21 https://dec.usaid.gov/dec/home/Default.aspx https://dec.usaid.gov/dec/home/Default.aspx https://extranet.who.int/countryplanningcycles/planning-cycle-files/health-sector-strategic-plan-hssp-v-2021-2026 http://api-hidl.afya.go.tz/uploads/library-documents/1641210939-jH9mKCtz.pdf https://mohz.go.tz/eng/ministry-different-strategies/ http://www.nmcp.go.tz/storage/app/uploads/public/643/90b/da8/64390bda839ac599662656.pdf http://www.nmcp.go.tz/storage/app/uploads/public/643/90b/da8/64390bda839ac599662656.pdf https://drive.google.com/drive/folders/1k-qFC0hua452y42FoQfTLqdGMLi9Iauv https://ntlp.go.tz/site/assets/files/1080/national_tuberculosis_and_leprosy_strategic_plan_vi_final_version.pdf https://tciurbanhealth.org/wp-content/uploads/2019/07/National-Family-Planning-Costed-Implementation-Plan-2019-2023-INSIDE-%E2%80%A2-F....pdf http://www.tzonline.org/pdf/TheHealthSectorHIVAIDs.pdf https://www.pmo.go.tz/uploads/documents/sw-1677564782-National%20One%20Health%20Strategic%20Plan%202022%20-2027.pdf https://www.mifugouvuvi.go.tz/uploads/publications/sw1679278889-%20%20TANZANIA%20ANTIMICROBIAL%20RESISTANCE%20NATIONAL%20ACTIO%20N%20PLAN%202023%20-2028.pdf https://extranet.who.int/sph/united-republic-tanzania-national-action-plan-health%20security-naphs-report used for decision making, THEN individuals, households, facilities, and communities will practice desired health behaviors.

Figure 1: USAID Thamini Afya (Value Your Health) Theory of Change

b) Result Framework

As shown in Figure 2 below, the goal of the Activity is to increase the practice of desired health behaviors by individuals (including healthcare providers), households and communities. To achieve this goal, the IRs, and sub-IRs are listed in the results framework below. All of the activities supported by the Activity should be suited to the Tanzania context and responsive to GOT needs and build on USAID/Tanzania investments.

Figure 2: USAID Thamini AFya (Value Your Health) Results Framework

To achieve the goal, IRs, and sub-IRs outlined in the results framework above, the Activity should use theory-informed, evidence-based SBC best practices as well as evidence uptake, capacity strengthening, and system strengthening best practices. Across all IRs, the Activity should explore, and where goals and values align, leverage private companies to spur innovation, efficiencies, and foster sustainability.

Intermediate Result 1

Specifically, for IR 1, the Activity will support coordination of SBC interventions by helping GOT to solidify the roles and responsibilities of the various government entities involved and operationalize them through the various national and sub national platforms including the national task teams which are made up of GOT counterparts from MOH, PO-RALG, Health Programs, donors, and service delivery partners, regional and district task teams.

a) Sub IR 1.1 The Activity will provide technical assistance to HPS of the MOH and the government Health Programs to better coordinate SBC interventions in the country. The Activity will also support defining roles and responsibilities of all SBC actors with the aim of minimizing duplication of efforts.

b) Sub IR 1.2

The Activity will provide technical assistance to PO-RALG, as well as local government health authorities, such as Regional and Council Health Management Teams (R/CHMTs) to better coordinate and implement SBC activities at health facilities and community levels.

c) Sub IR 1.3 The Activity will strengthen the capacity of USG service delivery partners to implement quality SBC interventions at the community and facility levels in their respective regions. In order to minimize duplication of USAID efforts, the Activity will be responsible for monitoring SBC interventions conducted by the USG service delivery partners through conducting joint supportive supervisions and providing mentoring when needed. The Activity will also be responsible for engaging and involving the USG SBC service delivery partners in all the national level SBC meetings for the partners to share available gaps and challenges in the community.

Intermediate Result 2

The Activity will support design of theory-informed, evidence-based SBC interventions using best practices, revamping SBC interventions supported by GOT, and ensuring that approved interventions are responsive to the needs of the community. To achieve this, the Activity is expected to work with all SBC stakeholders led by HPS/MOH to refine existing SBC interventions based on latest evidence from monitoring and other data. This will ensure that approaches are addressing relevant behavioral determinants and that USG service delivery partners are leveraging existing government platforms such as SITETEREKI (Unshakable), NAWEZA (I can) or the national-level HIV campaign FURAHA YANGU (My Happiness) to maximize consistency and economies of scale. New SBC interventions can be developed and co-created when there are relevant gaps to fill, such as to address additional priority behaviors, behavioral determinants, or target audience, to test a new approach such as a nudge based on behavioral economics, or when there is an outbreak of a disease or condition. Target populations, communities, USG service delivery partners and other stakeholders should be engaged in the design process. The Activity should support HPS/MOH to coordinate the stakeholders that need to be engaged for designing SBC interventions. Implementation modalities will be defined with inputs of USG service delivery partners. Innovative, cost effective and easy to implement interventions to reduce bias, foster empathy, increase compliance to treatment protocols and improve person-centered care among healthcare providers should be considered. Given the existence of SBC initiatives that have been tried and tested in the Sub-Saharan African region, it is anticipated that this Activity will conduct appropriate landscape analysis and make recommendations for adoption and adaptation to the Tanzanian context.

a) Sub IR 2.1 The Activity will ensure that existing SBC interventions are refined and adopted using primary and secondary data. Data coming from the health facility and community levels through USG service delivery partners and other sources should be used to refine existing SBC interventions.

b) Sub IR 2.2

The Activity will ensure that new SBC interventions are developed as needed using primary and secondary data. The design should incorporate data from the community and other sources. In designing new interventions, the Activity must work with HPS/MOH as a lead and ensure that other stakeholders managing SBC are engaged including community and private sector.

Intermediate Result 3

The Activity will be responsible for implementation, monitoring, and evaluation of SBC interventions at national, and at sub-national levels to support GHS SBC implementation and as needed for example in case of disease outbreaks.

a) Sub IR 3.1 The Activity will implement all SBC interventions at national level to avoid duplication of efforts across partners and stakeholders, access economies of scale in mass or social media or address social and behavioral determinants that cut across health areas such as norms, stigma and discrimination or agency. This national level implementation will serve to create an enabling environment and reinforce SBC interventions taking place at the community or facility level.

b) Sub IR 3.2 The Activity will implement SBC interventions sub-nationally at the community and facility level for all global health security (GHS) interventions and for other health areas, as needed. There are currently no USG service delivery partners that are implementing SBC interventions for global health security sub-nationally at the community or facility levels. The Activity will also implement SBC interventions at sub-national level in the cases of new disease outbreaks as needed.

c) Sub IR 3.3 The Activity will support data collection (and coordination of data collection), analysis, and dissemination for the monitoring of intermediate outcomes (the behavioral determinants) and behavioral outcomes to support GOT, communities, stakeholders and partners to make evidence-based, data-driven decisions about strategies and operational plans. While ensuring adequate reach and coverage of targeted populations is essential, monitoring, evaluation and learning efforts will need to go beyond measuring these process indicators. Monitoring relevant behavioral determinants and behavioral outcomes and assessing the effect of SBC on service uptake are critical to ensure sustained investments in SBC across health areas. The Activity may need to collect data for monitoring and evaluation purposes; however, where possible, existing data and data collection approaches should be used.