NOFO 72068724RFA00007 USAID MIAHY Signed.pdf

Issue Date : October 7, 2024 Deadline for Questions : October 26, 2024 Closing Date : November 27, 2024 Closing Time : 23:59, Madagascar time, (GMT+3)

Subject : Notice of Funding Opportunity (NOFO) Number: 72068724RFA00007 Program Title : USAID Access Miahy Federal Assistance Listing Number : 98.001

Ladies/Gentlemen:

The United States Agency for International Development (USAID) is seeking applications for a Cooperative Agreement or grant from qualified entities to implement the “USAID Access Miahy”. Eligibility for this award is not restricted.

USAID intends to make ONE OR MORE award(s) 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 D.6.g. The registration process may take many weeks to 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 G. 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, Orion Yeandel, Agreement Officer http://www.grants.gov/ mailto:support@grants.gov

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TABLE OF CONTENTS

SECTION A: PROGRAM DESCRIPTION

A.1. INTRODUCTION

A.2. OVERVIEW

A.3. LINK TO CDCS, PROBLEM ANALYSIS AND THEORY OF CHANGE

A.4. PROGRAM OBJECTIVES

A.5. GEOGRAPHIC SCOPE

A.6. ACTIVITY PARAMETERS AND CROSS-CUTTING CONSIDERATIONS

A.7. ENVIRONMENTAL COMPLIANCE

A.8. CLIMATE RISK MANAGEMENT

A.9. Monitoring, Evaluation, and Learning (MEL) and Collaboration, Learning and Adaptation (CLA)

SECTION B: FEDERAL AWARD INFORMATION

SECTION C: ELIGIBILITY INFORMATION

SECTION D: APPLICATION AND SUBMISSION INFORMATION

SECTION E: APPLICATION REVIEW INFORMATION

SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION

SECTION G: FEDERAL AWARDING AGENCY CONTACT(S)

SECTION H: OTHER INFORMATION

ANNEX 1 - BUDGET TEMPLATE (See attached)

ANNEX 2 - STANDARD PROVISIONS

REQUIRED STANDARD PROVISIONS FOR U.S. NONGOVERNMENTAL ORGANIZATIONS

REQUIRED STANDARD PROVISIONS FOR NON-U.S. NONGOVERNMENTAL ORGANIZATIONS .. 52

ANNEX 3 - INITIAL ENVIRONMENTAL EXAMINATION

ANNEX 4 - GENDER ANALYSIS

ANNEX 5 - PAST PERFORMANCE INFORMATION TEMPLATE

ANNEX 6. USAID Madagascar updated Country Development and Cooperation Strategy (CDCS) 55

ANNEX 7. Revised In-Country Per Diem, Lodging, and Transportation Payments to Government of Madagascar Officials, Civil Society Organizations, and Private Sector Staff and Stipends for Community Health Volunteers Mission Order 300 dated March 18, 2023

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SECTION A: PROGRAM DESCRIPTION

A.1. INTRODUCTION

Through this Notice of Funding Opportunity (NFO), the United States Agency for International Development (USAID) intends to implement an activity to save lives, decrease disease, and increase the potential of women, newborns, children, and communities to thrive by increasing the quality and equity of services, reducing mortality and increasing coverage of lifesaving interventions through the support of the primary health care (PHC) system in Madagascar.

USAID sees strengthening primary health care as the key to restoring essential service provisions and getting global survival rates to better than pre-pandemic levels by 2025 (G7 Japan 2023 Foreign Ministers’ Communiqué) – especially for children under five and people under 50– and building health system resilience for the future. Our focus on mortality in children under five and people under 50 is critical as these populations benefit from nearly all flagship USAID health programs and constitute much of the preventable, premature deaths that occur in low- and middle-income countries. PHC also serves as the first line of defense against emerging infectious diseases, making it a key tool to enhance pandemic preparedness and outbreak response. In increasing PHC and health systems support, there is an opportunity to reclaim lost ground from the COVID-19 pandemic by bolstering health systems and investing in health care workers to further strengthen the foundation on which our health programs and initiatives rely.

The purpose of USAID’s health portfolio in Madagascar is to improve health outcomes among underserved populations through improved healthy behaviors and increased access to quality health services. More specifically, USAID/Madagascar’s work in the health sector aims to reduce maternal and child morbidity and mortality and support efforts towards progressive and geographic malaria elimination. Access to and utilization of primary health care facilities continues to be a challenge as the country faces a myriad of health systems challenges including a dearth of qualified health workers, medical and commodity insecurity, and weak health and management information systems. Access Miahy is designed to address these challenges by building the capacity of the Government of Madagascar (GOM)/ Ministry of Public Health (MOPH) actors to design, develop, manage, deliver, monitor, and evaluate quality health services within their districts. In line with USAID's commitment to working more directly with local organizations, the activity will ensure that local actors lead efforts, local systems are strengthened, and work is responsive to local communities.

A.2. OVERVIEW

A.2.1. BACKGROUND and Problem Statement

1. Country context and health situation

Madagascar is the world’s fourth largest island, situated in the Indian Ocean off the coast of southern Africa. Despite considerable natural resources, its population of nearly 30 million (2024) has one of the world’s highest poverty rates and faces enormous social and economic

72068724RFA00007 USAID Access Miahy Page 4 of 55 development challenges. Hence, Madagascar struggles with slow growth and persistent poverty, weak governance, inadequate human and physical capital development, and slow structural transformation. Climate crises and extreme vulnerability to external shocks are increasing and exacerbating poverty, and the population is growing so rapidly that the economy cannot keep

up. Madagascar has one of the highest poverty rates in the world, reaching 75% in 2022 of Malagasy people living below the national poverty line. These situations inhibit development and investment; and, as a result, Madagascar’s progress on health indicators has faltered and, in some cases, reversed.

Maternal mortality has stagnated at 426 maternal deaths per 100,000 live births over the past twenty plus years. Maternal deaths are mainly due to complications of pregnancy or birth-related complications. Alarmingly, a third of this mortality occurs among adolescents. The adolescent fertility rate is high and 151 out of every 1,000 girls give birth between the ages of 15 and 19. The use of modern contraceptives has increased; the modern contraceptive prevalence rate (mCPR) increased from 43% in 2021 to 46% in 2023 but the rate in urban areas has slightly decreased according to the values produced using Track20's The Family Planning Estimation Tool model. The unmet need for family planning (FP) in Madagascar decreased to 15%.

Between 2018 and 2021, the under-five mortality increased significantly from 60 to 75 deaths per 1,000 live births. In the 23 regions surveyed, the prevalence of Acute Respiratory Illness (ARI) among children was 2%, with 54% of affected children seeking advice or treatment. Additionally, 90% of children experienced diarrhea, but only 41% sought medical advice or treatment, and 50% received Oral Rehydration Therapy (ORT) (DHS, 2021). 100 children die each day from preventable causes and, despite improvements in performance in immunization, the zero-dose child rate is among the highest in the region. Madagascar is among the top 10 countries globally with the highest numbers of measles zero dose in 2022 and has faced numerous vaccine preventable disease outbreaks including measles over the years. The country has also faced an outbreak of vaccine-derived poliovirus (cVDPV), further pointing to underlying immunity gaps.

In addition, malaria remains endemic in all the 23 regions and is causing a high rate of death among children, thus persisting as a major public health issue. In 2023, there were an estimated

2.9 million cases of malaria (an increase from 1.6 million cases in 2022), causing approximately 400 deaths (an increase from 282 deaths in 2022). Increases in malaria burden are seen across the island, including in the central highlands, and among people of all age groups.

The most recent Demographic Health Survey (DHS 2021) showed a decline in the number of children who were fully vaccinated to 49%, a decrease from 62% in the 2008/2009 DHS. The percentage of zero dose children also worsened within this period from 13% in 2008/2009 to 18% in 2021. This decline is also seen in the annual WHO UNICEF Estimates trends which show declines of 77% to 66%, 70% to 57%, and 60% to 44% of one dose of diphtheria, pertussis, and tetanus vaccine (DPT1), three doses (DPT3), and one dose of measles vaccine (MCV1)

72068724RFA00007 USAID Access Miahy Page 5 of 55 respectively. MCV2 rates are also very low. There are regional variations in immunization rates, with the lowest in SAVA region.

Among the reasons for the decline in all vaccines coverage rate was the COVID 19 pandemic in 2020-2021.

Malnutrition is pervasive throughout Madagascar and varies sub-nationally due to environmental conditions, diets, illness, and access to health services. Nearly 40% of children under five years are stunted (2021 DHS), which indicates that the environments to which children are exposed are suboptimal as there are many drivers of stunting related to health beyond nutrition. This is one of the highest stunting rates globally (2024 GNR). 7.7% of children are wasted, but wasting rates are different regionally and seasonally (2021 DHS). About 23% of children are underweight. Only 54% of children are exclusively breastfed and only 22% of children consume a diet of minimum diversity. Vitamin A supplementation among children is also low at 38% while only 20% of pregnant women consume iron-containing supplements for 90+ days (2021 DHS). This demonstrates that the inclusion of nutrition in health services and coverage of nutrition interventions is suboptimal. Given that undernutrition is a leading cause of maternal, neonatal, and child morbidity and mortality, increased access and availability of nutrition services through primary health care is critical.

Closely associated with undernutrition is inadequate Water, Sanitation, and Hygiene (WASH).

40% of Malagasy children under age five are stunted, with studies validating a direct link between open defecation (coupled with the lack of clean water and poor hygienic practices) and cases of diarrhea and chronic malnutrition. The limited access to clean water, high rates of open defecation, improper handling of children’s stools and poor hygiene behavior has resulted in transmission of water borne diseases. Diarrhea is the second leading cause of child mortality in Madagascar, with 10% of under-five mortality attributed to diarrhea. Increasing sanitation coverage has been slow over the past 20 years across the country, and the east and the southwest remain at less than 10% coverage. Low access rates are exacerbated by local taboos and lack of low-cost and culturally acceptable technologies, notably for areas with sandy soil or high-water tables.

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Due to inadequate services and financial neglect, over 80% of individuals with mental health conditions lack access to necessary services. Mental health services in Madagascar are severely neglected, with a shortage of both specialists and lack of trained staff at the primary health care level, and insufficient funding, health, and social services, to support those who suffer from mental health disorders.

2. Previous USAID Investments

Following the end of the political crisis in 2014, USAID renewed its engagement with the GOM and transitioned from providing humanitarian support to building the health system. In 2018, USAID awarded its flagship integrated health program (Accessible Continuum of Care And Essential Services Sustained: ACCESS) which aimed to improve health outcomes through investments in district health systems, promote capacity building for better service quality, and implement social and behavior change. The program built upon previous investments in community health and clinical service delivery, and consolidated efforts to reinforce the continuum of care and strengthen district level planning and management.

USAID has made significant strides at the community level through strategic investments and targeted initiatives. By funding projects to train community health workers (CHWs) using customized curricula aligned with national policies and strategies.USAID has employed two different approaches to community health through separate projects in distinct areas of intervention. Focusing on the quality of CHW services, program staff identified high performers and established a new cadre of 1,700 CHW peer supervisors. A national package of essential services curricula was developed and was adopted by all donors, thereby enhancing CHW service quality through a peer supervision model. Looking ahead, USAID plans to work with the MoH to increase the number of CHWs and peer supervisors, adapting to population size and geography, while also focusing on sustainability through a dedicated Sub-Intermediate Result that addresses CHW motivation and activity financing.

At the district level, USAID is supporting leadership, management and data-driven decision-making to improve performance of district health teams and Centre de Santé de Base (CSBs).

USAID has supported capacity building for human resources and introduced nationally adopted quality assurance and quality improvement approaches, particularly at the district, CSB and community level. This includes investing in the improvement of service delivery and quality through increased clinical training in maternal, neonatal and child health (MNCH) nutrition, family planning, and malaria programming for health providers at CSBs and district hospital levels. USAID has also supported the update of the National Health Information System and the new Digital Health Strategy. The DHIS2 software for routine data reporting is now functional in all 114 districts across the country. In addition, the community health software, CommCare, which is used for reporting and orientation of treatment for CHWs, has been adopted by the MOPH and is currently used by more than 4,000 CHWs.

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A.2.2. ACTIVITY GOAL AND OBJECTIVES

Access Miahy Goal: Accelerate sustainable reductions in MNCH morbidity and mortality through increased access to and availability of quality PHC services.

Access Miahy Objectives: Build the capacity of MOPH actors and other relevant stakeholders at district, facility and community levels to design, develop, manage, deliver, monitor and evaluate health services and programs aligned with the intervention packages in their catchment areas.

A.3. LINK TO CDCS, PROBLEM ANALYSIS AND THEORY OF CHANGE

A.3.1. LINK TO CDCS

The Access Miahy activity will support the Madagascar Country Development Cooperation Strategy (CDCS) for 2020 to 2025, particularly Development Objective (DO) 1: "Improved Human Capacity to Contribute to the Country’s Journey to Self-Reliance." To achieve this, the interventions will focus on several key areas. Firstly, they aim to accelerate sustainable health impacts (IR 1.1) by promoting health and care-seeking behaviors and social norms (Sub-IR 1.1.1).

Additionally, the interventions will increase the availability of and accessibility to a continuum of quality health, nutrition, and WASH services (Sub-IR 1.1.2). Another critical aspect will be the mobilization and optimization of resources for health and WASH (Sub-IR 1.1.3). Lastly, the initiative will strengthen governance, management, and leadership in these sectors (Sub-IR 1.1.4), ensuring a robust framework to support the overall strategy. The Access Miahy activity is also planned to align with the Development Objectives related to human capability improvement of the forthcoming 2025-2030 Country Development Cooperation Strategy, which is in development. This activity is expected to contribute substantially to health, nutrition and WASH sector development outcomes.

USAID will strengthen the GOM’s ability to sustain its own development agenda by increasing the mobilization of domestic resources for health, engaging the private sector to expand delivery of quality products, scaling-up effective health financing strategies that increase financial protection for the poor, and improving service delivery efficiencies. It will support improvements in data quality and collection (including local level sex-disaggregated data), and build country capacity for analyses and the use of data for decision-making.

Across USAID’s strategy, programs will work to address gender inequality to make USAID’s development interventions more effective and inclusive. USAID will promote healthy and gender-equitable behaviors and social norms to reduce threats such as maternal, newborn, and child morbidity, child early forced marriage (CEFM), gender-based violence (GBV), time poverty, and limited decision-making ability among women.

A.3.2. PROBLEM ANALYSIS

Low Availability of Qualified Human Resources for Health (HRH)

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The public health system in Madagascar faces a critical shortage of qualified human resources, particularly below the central level. This shortage is exacerbated by the uneven distribution of health workers, with a significant concentration in urban areas, especially the capital. Seventy-two percent of medical doctors serve only 21% of the population in urban regions, while 26% of healthcare personnel, including doctors, dentists, and paramedics, are concentrated in the Analamanga Region. This imbalance leaves rural areas and other regions severely understaffed (less than one doctor for every 10,000 inhabitants), compromising the equitable delivery of healthcare services across the country.

Limited Financial Resources for Health Districts and Community Health

Public financing of the health sector in Madagascar is significantly lower compared to other low-income countries in Sub-Saharan Africa. The Analamanga Region receives a disproportionate share of health funds, while other regions suffer from insufficient budget allocations. This financial imbalance and inadequate budget allocation to decentralized structures lead to chronic underfunding of health districts, which lack both financial resources and decision-making autonomy.

Financial resources for implementing the National Community Health Policy are notably insufficient. Current funding for community health relies heavily on external donors and health partners. The government's budget does not allocate funds for community health activities, especially in districts not supported by these partners. Additionally, the lack of remuneration for Community Health Workers contributes to the frequent turnover of trained staff, further destabilizing the provision of consistent care.

Limited Health System Reach

In Madagascar, approximately 66.17% of the population faces difficulties in accessing care, exacerbating health inequalities. A significant portion of the population lives more than 5 km away from health facilities, creating substantial barriers to accessing care. Geographic, financial, and cultural barriers prevent many individuals from receiving necessary health services.

Infrastructure issues, such as the lack of accessible roads in many regions of the island, especially during the rainy season, further impede access to healthcare. The COVID-19 pandemic further strained the health sector, highlighting the urgent need to address these access issues.

Use of Data for Decision-Making

The community health information system needs integration into the national health information system (HIS) to ensure cohesive data management. While community RMA (Activities Monthly Report) data is available in DHIS2 and the Community Health Implementation Guide emphasizes digitalization, challenges remain. The shortage of HIS equipment, inadequate management, network coverage issues, and a lack of dedicated data management staff impede

72068724RFA00007 USAID Access Miahy Page 9 of 55 effective data utilization. Additionally, poor coordination of donor resources and the absence of independent financing hinder improvements in the health information system. Despite real-time data availability in DHIS2, insufficient data reporting from community and private health facilities, coupled with a lack of a data-driven decision-making culture, limits the system's effectiveness.

Quality Improvement

Ensuring quality service provision at the community level is challenging due to inadequate technical supervision of CHWs by CSB health workers. CSB leaders often fail to fulfill their supervisory roles due to a lack of awareness, ownership, and overwhelming workloads.

Consequently, supervision activities are insufficient, leaving donor and partner staff to fill this critical gap. A World Bank survey revealed that only 17.2% of CSB II ( Centre de Sante de Base level 2) and 73.5% of district hospitals offer basic and comprehensive emergency obstetric care.

Diagnostic accuracy for common illnesses is alarmingly low, and adherence to clinical guidelines for maternal and neonatal complications is poor. Additionally, less than 50% of health facilities possess standard technical guidance, and many lack essential resources such as clean water, critical for infection prevention and control. Despite the MOPH prioritizing quality improvements, resource constraints severely limit advancements in service provision, infrastructure cleanliness, and reception, particularly in district hospitals and CSBs.

A.3.3 THEORY OF CHANGE

IF the Access Miahy activity leverages a continuous quality improvement approach at the community, facility, and district levels to support access to and quality of PHC services by:

1. Increasing management capacity at the subnational and facility levels and expanding service coverage,

2. Strengthening governance and accountability, including through community engagement in priority setting and social accountability, and

3. Engaging Malagasy people to sustainably adopt healthy behaviors and social norms, and utilize available health services, THEN the capacity of MOPH to design, develop, manage, deliver, monitor, and evaluate health services will be strengthened. Programs will align with intervention packages in their catchment areas, leading to increased access to and availability of quality PHC services—encompassing preventive, promotive, and curative care—in the targeted regions. This will accelerate and sustain reductions in MNCH morbidity and mortality.

A.4. PROGRAM OBJECTIVES

The Access Miahy approach must be client-centered and respectful of and responsive to the individual’s life experiences and socio-cultural values while anticipating other health needs for

72068724RFA00007 USAID Access Miahy Page 10 of 55 the client or family members as appropriate. All approaches and interventions in this activity should be adapted to underserved areas and gender characteristics including but not limited to remote populations, youth, people living with disability and other vulnerable groups.

The Access Miahy activity will focus on how Malagasy people can effectively access promotive, preventive and curative services across the district health system consisting of CHWs, CSBI and II, and district level hospitals under the support oversight of the District Health Service. At times and in certain districts, this may involve more significant involvement than in others. However, building on the gains from the ACCESS program, the intent is to support the MOPH and increase its ownership and capacity to effectively manage health activities. While support will be focused on the district health system, it is essential that the recipient work closely with relevant central MOPH directorates to ensure ownership, accountability, and sustainability.

Access Miahy RESULTS FRAMEWORK

LOGIC MODEL

ACCESS Miahy Goal: Accelerate sustainable reductions in maternal, neonatal and child morbidity and mortality through increased access and availability of quality PHC services ACCESS Miahy Vision: Build the capacity of MOPH actors at district, facility and community levels to design, develop, manage, deliver, monitor and evaluate health services and programs aligned with the intervention packages in their catchment areas.

Objective 1:

Capacity is increased at the subnational, facility, and community levels to expand the reach of, and improve provider performance to deliver, high-quality PHC services

Objective 2:

Subnational leadership, governance, and accountability are strengthened to ensure long term sustainability of PHC services

Objective 3:

The Malagasy people sustainably adopt healthy behaviors, social norms and use available health services

1.1 Improved performance among

CSB staff and community health volunteers to deliver quality care at first point of contact with the health system

1.2 Expand proactive community

service delivery and networks of care

1.3 Expanded use of data to inform

continuous improvement of clinical care and programmatic decision making

1.4 Priority quality improvement

goals are identified across community, facility and district levels to address gaps in FP/RH, MNCH, immunization, malaria, nutrition and WASH services and behaviors

2.1 Increased leadership and

management at the regional and district levels to support PHC service delivery

2.2 Existing community structures

are leveraged to solicit input into PHC planning, including budget and service delivery

2.3 Feedback mechanisms are

strengthened or developed to support social accountability of the health system to the community

2.4 Sustainability mechanisms are

developed for community health activities.

3.1 Communities and

institutions promote and support healthy behaviors

3.2 Barriers to healthy and

health seeking behaviors for the poor and underserved are reduced

Institutionalize continuous quality improvement at community, facility and district levels

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1. Objective 1 - Capacity is increased at the subnational, facility, and community levels to expand the reach of, and improve provider performance to deliver, high-quality PHC services.

1.1 Improved performance among health care providers to deliver quality care at first point of contact with the health system

Access Miahy will improve performance among CSB staff and community health workers to deliver quality care at the first point of contact with the health system. Delivery of high-quality, person-centered care in a PHC–oriented health system relies on a committed, multidisciplinary workforce that has sufficient staff with the right competencies who can be appropriately distributed to deliver facility-, outreach- and community-based care. Access Miahy will ensure that health care providers have the appropriate knowledge and skill to offer quality services to address the key causes of maternal, newborn, and child mortality. Emphasis should be placed on high-impact evidence-based interventions to prevent and respond to malaria, acute respiratory infection (ARI), and diarrhea; expand family planning services; and offer quality ante-natal, perinatal, and post-natal care services. The recipient will ensure CSB staff and community health workers have the appropriate competencies to provide quality services placing emphasis on mentorship, supportive supervision, coaching and other forms of on-the-job learning covering a comprehensive package of essential health and nutrition services. Activities to build health workforce capacity will be done with the leadership of the MOPH and in collaboration with other relevant stakeholders, with the aim of having government leading future capacity building efforts. Activities will consider the ecosystem of influences on provider behavior and go beyond training and mentorship to ensure that other key determinants of provider behavior are addressed to improve quality of service delivery and experience of care. This includes consideration of the diverse factors that influence provider behavior and how they interact with one another in a system such as provider support, organizational norms, power dynamics, and an enabling environment for quality improvements.

The program will introduce interventions that increase the autonomy of CSB staff to function as funds managers in order to be able to better respond to health facility and patient needs. These management functions should include proactive planning, budgeting and expenditure accounting at the CSB level across all funding sources including “donation CSB funds”. The recipient will also provide support to Commission Communale de Développement Sanitaire (CCDS) to effectively and efficiently review budget and resource requests from CSBs.

The recipient shall strengthen health sector staff performance through the expansion of current quality assurance mechanisms (AQS) with particular attention to high impact MNCH, malaria, HIV, family planning and nutrition interventions at the CSB and community levels to address the leading causes of maternal, neonatal, and child morbidity and mortality. Particular attention will be paid to applications that include continuous quality improvement as a strategy for capacity building and incentivize actors to apply new learning and build relationships as a means to mentor and increase capacity.

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Should Madagascar receive future HIV funding, Access Miahy may also integrate some HIV services including testing during antenatal care (ANC). With the currently in-process guidelines on task sharing, MoH has expanded the services that non-physician staff are able to perform, including the full 3 HIV test confirmation service. Additionally, postpartum, the Prevention of Mother to Child Transmission (PMTCT) cascade continues with care for the HIV-exposed infant (HEI), including medical prophylaxis for the HEI and viral HIV testing (early infant diagnosis=EID) using the available GenXperts in Madagascar.

The program will also provide limited support to district hospital provider performance with focus on maternity services and management of severe malaria. Access Miahy should leverage investments from other donors such as World Bank and the European Union in health facility equipment and infrastructure to support service quality improvement for safe surgery. Access Miahy should leverage the investments of Global Fund of antiretroviral drug procurements to provide antiretroviral therapy (ART) to the pregnant women identified at their PMTCT pilot sites.

Access Miahy shall contribute to the integration of Mental Health and Psychosocial Support (MHPSS) into the primary health care package of services, leveraging results from other USAID-supported mental health activities. This integration will involve several key activities: training health providers, including CSB staff, community health workers, and matrons, to deliver MHPSS services, utilize screening tools, and manage referrals effectively. Additionally, there will be a focus on improving the skills of health providers and community health workers to promote mental health-seeking behaviors among the population. Finally, mental health data will be incorporated into the existing reporting system, utilizing CommCare software to streamline data collection and analysis.

Access Miahy will commit to strengthening the preparedness of the Malagasy health system to effectively respond to both anticipated and unforeseen health crises throughout the project's duration. By reinforcing the district health system, including Community Health Workers (CHWs), CSB I and II, and district-level hospitals, Access Miahy will ensure that vital health services are accessible, resilient, and adaptable in the face of emergencies. The project will contribute to building the capacity of the Ministry of Public Health (MOPH) to manage health activities autonomously while fostering collaboration between district and central levels to guarantee a coordinated and rapid response. Through targeted support, training, and resource allocation, Access Miahy will aim to enhance the health system's agility, ensuring that it is equipped to protect and promote the health of the Malagasy population, even under the pressures of unforeseen crisis

1.2 Expand proactive community service delivery and networks of care

Building upon existing subnational service delivery models, Access Miahy will ensure that facility- and community-based PHC delivery is well defined for, and implemented by, multidisciplinary teams of health care workers. Service delivery should include outreach to communities for preventive and promotive health services, case finding and treatment, and two-

72068724RFA00007 USAID Access Miahy Page 13 of 55 way referral protocols that promote comprehensiveness, coordination and continuous care through functional or physical integration of service delivery across vertical health areas.

The recipient will expand service availability through adapted and co-created approaches to enhance community access to preventive, promotive, curative and services with attention paid to timely and complete immunization, particularly for unreached populations, and expansion of ANC services with intermittent preventive treatment in pregnancy (IPTp) and skilled birth attendance for pregnant women. The recipient will offer approaches that include both planning (i.e. better mapping of target populations) and outreach (i.e. expanding the number and reach of CHWs and mobile clinics) and will include strategies for ensuring continuous service delivery during climate incursions and other shocks. Building on previous ACCESS program experience and lessons, the recipient will improve the reach and quality of malaria intensified community-based interventions targeting high burden municipalities in select districts. The number and distribution of CHVs should be aligned with population numbers and geographic access challenges in alignment with Madagascar’s Guide de Mise en Oeuvre Pour la Santé Communautaire. Additionally, Access Miahy will train the CHVs on the Integrated Community Case Management (iCCM) module on HIV screening and referral to increase community awareness and improve the reach of HIV assessments and referrals to facility services.

The activity will also support communities and health facilities to put in place proactive measures to respond to potential public health emergencies and climate-related shocks.

1.3 Expanded use of data to inform continuous improvement of clinical care and programmatic decision making.

Access Miahy will also expand the use of data to inform continuous improvement of clinical care and programmatic decision making. The program will work with the Country Health Information Systems and Data Use (CHISU) activity and its follow on to support management of information systems to ensure timely reporting of quality data–logistics, financial, clinical, and performance management– which can be used for planning, monitoring and evaluation, and decision making.

The recipient will support the continued rollout of, and support to, CommCare at facility and community levels. This may include understanding barriers providing material support in the form of phones and airtime to expand CommCare in areas where it has not already been established as well as training relevant CHWs in its use for clinical decision making. The recipient will also train staff and CHWs on relevant data tools (including but not limited to CommCare), timely and complete reporting, and creating and using dashboards and other data visualization tools for decision making at the CSB and community levels. To inform continuous improvement and priority setting, the recipient will carry out periodic data quality assessments (DQA) and regularly assess patient and client experience and satisfaction.

1.4 Priority quality improvement goals are identified across community, facility and district levels to address gaps in FP/RH, MNCH, immunization, malaria, nutrition and WASH services and behaviors.

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Access Miahy will identify priority quality improvement (QI) goals across community, facility and district levels to address gaps in FP/RH, MNCH, immunization, malaria, nutrition and WASH services and behaviors. QI support activities will be provided to address these goals, and the recipient will establish and/or strengthen QI collaboratives in priority districts and communities.

Each QI collaborative will be composed of multiple teams that are working/will work on common aims and indicators to continuously improve health care processes related to FP/RH, MNCH, immunization, malaria, nutrition and WASH services and behaviors. Within these QI collaboratives, the recipient will build the capacity of local government and health facility leadership to identify and support QI focal points, QI coaches, and QI teams at the district facility. At a community level, QI should be linked to social and behavior change (SBC) efforts under Objective 3 . Each QI focal point, QI coach, and QI team member should have clearly defined roles and responsibilities. The recipient will work closely with local government and the QI coaches to establish and facilitate a system of quarterly learning sessions. The learning sessions will bring together QI teams from the participating facilities in the QI collaborative, who are working on the same problem(s) to share experiences and lessons learned based on their shared QI goals and indicators. The recipient should also incorporate low intensity clinical training in the QI collaborative coaching support to ensure compliance with evidence-based standards and practices.

1.5 Improved service delivery by focusing on provider behavior change to improve quality & experience of care.

Support providers to improve service delivery to ensure a high quality, respectful experience for individuals and families in health facilities and community platforms. Utilize proven provider behavior change tools (such as the provider behavior ecosystem) and strategies to support changes in behaviors and associated norms, including addressing environmental and systemic factors such as inhibitive policies or processes. Support research to identify promising approaches to enhance client-provider interaction and improve experience of care. This also includes efforts towards supportive environments for providers, respectful care, nurturing care, adherence to protocols, client-provider interaction, and any other efforts at the provider, facility, and systems-level.

2. Objective 2 - Improved governance and accountability at all levels of the health system for PHC

2.1 Increased leadership and management at the regional and district levels to support PHC service delivery.

Access Miahy will support capacity building efforts to improve leadership and management at the regional and district levels for PHC delivery including FP/RH, MNCH, immunization, malaria, nutrition and WASH. This will build on existing efforts to build leadership and management capacities for PHC and will engage local community members and civil society organizations in PHC priority setting, design, and monitoring. The recipient will improve leadership and https://breakthroughactionandresearch.org/resource-library/provider-behavior-ecosystem-map/

72068724RFA00007 USAID Access Miahy Page 15 of 55 management through focused interventions to improve leading, managing and governing capacities and overall performance of regional and district health management teams in accordance with their recently updated SOPs. The recipient will ensure there are clearly defined roles and responsibilities among the District Health Management Team (DHMT) and Regional Staff for improving supportive supervision and QI coaching support to facilities and CHVs. The recipient will build on the Leadership Development Program Plus (LDP+) approach to increase coordination across various structures at the subnational level in particular including supporting community health work, program and MOPH regional staff, champions and other community outreach volunteers and partners. Among the responsibilities of the DHMT will be to oversee CSB staff and community health workers to deliver quality care at the first point of contact with the health system. This responsibility requires human resources for health (HRH) management competencies in budget and performance management to be able to deploy effective management supervision, provide appropriate compensation and offer high-quality PHC services.

2.2 Existing community structures are leveraged to solicit input into PHC planning, including budget and service delivery

Access Miahy will leverage community structures to solicit input into PHC planning, including budget and service delivery. The existing structures are important starting points to build on, though other community structures may be identified and deployed if found to be effective in the design, implementation and monitoring of PHC services, especially in underserved communities. The recipient will also actively provide opportunities for individuals and community groups (CCDS, youth groups, Savings and Internal Lending Communities (SILCs), Civil Society organization (CSOs) to participate in existing coordination mechanisms (e.g. village committee). The recipient will support the strengthening of existing and establishing of new locally led QI teams and ensure clear understanding and operationalization of quality improvement processes. A key component will be to use the Plan-Do-Study-Act (PDSA) cycle to identify goals, test and measure change across the prioritized health areas. The recipient will emphasize the development, promotion and use of the locally tailored community action plans to address identified needs and goals.

2.3 Feedback mechanisms are strengthened or developed to support social accountability of the health system to the community.

Access Miahy will strengthen existing feedback mechanisms or develop appropriate mechanisms for social accountability of the health system to the community. Social accountability offers a set of approaches and tools to promote citizen engagement and monitoring to improve system performance, effectiveness, and responsiveness to public needs.

Effective social accountability measures require both system-level action– data transparency and government responsiveness– as well as user action, representative participation and citizen-led oversight. The recipient will strengthen and undertake accountability mechanisms with the

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CCDS, regional and district MOPH teams to ensure actions, decisions and resources are used effectively and equitably. The recipient will support social accountability mechanisms to ensure ordinary citizens and/or civil society organizations participate directly or indirectly in advocating for quality PHC services, positive experiences of care, tracking progress, reviewing community health status, and exacting accountability. There are a number of existing community-based organizations such as (SILCs, Youth Corner) the recipient should leverage to build local health literacy, develop community-based accountability mechanisms that address participation in health governance, planning and priority setting and implementation.

2.4 Sustainability mechanisms are developed for community health activities.

Access Miahy will ensure sustainability mechanisms are developed to maintain community health activities. These will be part of the design and co-creation process from the outset and will be strengthened throughout the project. The recipient will explore mechanisms through both the MOPH and the Ministry of Interior and Decentralization to improve professionalism and motivation for CHWs. While continuing to contribute to the CHWs financial and nonfinancial motivation, aligned the national guideline for Community health (Guide de Mise en oeuvre harmonisée du programme de santé communautaire à Madagascar), the recipient will develop and strengthen mobilization of local resources to support community health operation costs.

The mobilization of local resources will also be linked to national level efforts for advocacy and evidence sharing.

3. Objective 3 The Malagasy people sustainably practice healthy behaviors, supportive social norms, and utilize available health services

USAID envisions that Access Miahy will work at the community, facility, district, and national levels to increase the adoption and sustained practice of priority healthy behaviors. The activity should employ an evidence based, multi-faceted approach to social and behavior change that aims to address individual, community, and facility level barriers to change. The recipient should review existing data, triangulate available information, conduct formative research as necessary to identify priority behaviors, and design tailored interventions in its regions of implementation.

This includes working with communities to understand root causes of certain behaviors and practices, including social and cultural norms, underlying factors (like resource availability, desirability, accessibility) and establishing trust to collaboratively find solutions that are contextually appropriate and accessible, including leveraging innovative or supportive technologies where feasible (such as social media platforms). The role of CHWs will be vital to these efforts, and therefore, ensuring that they have the most up-to-date information and skills for engaging with the community via multiple entry points will be a key component of this activity.

Some of the current national-level priority behaviors include: use of FP (including postpartum);

proper and consistent use of Long-lasting insecticidal nets (LLIN); improved maternal nutrition;

early and consistent attendance of ANC (including IPTp), care-seeking for pregnancy danger

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complementary feeding; household water treatment; latrine use; handwashing with soap; care-seeking and treatment for infant and child illness (especially malaria, diarrhea, respiratory infections and other fever), treatment adherence, and immunization.

3.1 Improved behavior change activities that promote optimal health practices among beneficiaries.

Multiple stakeholders each play important roles in promoting and supporting healthy behaviors including national-level stakeholders, frontline healthcare workers, community health workers, religious leaders, and community groups. The applicant will support national and decentralized capacity strengthening activities in SBC theory, strategy development and implementation.

Activities include working with local institutions and communities to lead SBC activities that are locally acceptable, appropriate and will strengthen community support and help sustain local engagement. This is central to the USAID localization effort to center and elevate local voices and solutions, ensuring that activities are locally led. These efforts will support improving healthy behaviors at the household and community as well as support agencies to demand quality services at facilities.

3.2 Improved social and gender norms that support healthy practices.

Identifying and addressing underlying factors and barriers to health behaviors and encouraging adoption of positive behaviors through proven SBC approaches is key to improving individual and community health. Community health workers, community leaders, religious leaders, and other key stakeholders play a critical role in facilitating normative change to ensure acceptability and appropriateness of approaches.