NOFO - HSS.pdf

Issue Date: September 12, 2024

Deadline for Questions: September 20, 2024; 5:00 p.m. India Local Time

(Response to questions will be provided through an amendment to NOFO at https://www.grants.gov)

Closing Date and Time: October 29, 2024; 5:00 p.m. India Local Time

Subject: Notice of Funding Opportunity (NOFO):72038624RFA00004

Program Title: Health Systems Strengthening (HSS) Activity

Federal Assistance Listing Number: 98.001

All Interested Parties, The United States Agency for International Development (USAID/India) is seeking concept papers for a Fixed Amount Cooperative Agreement from qualified entities to implement the “Health Systems Strengthening (HSS) Activity.” Eligibility is open to all U.S., local, and international non-governmental organizations.

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

Eligible parties interested in submitting a concept paper are encouraged to read this NOFO thoroughly to understand the type of program sought, submission requirements and the 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. The registration process may take many weeks to complete. Therefore, applicants are encouraged to begin registration early in the process.

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, concept paper or an application. Concept Papers are submitted at the risk of the applicant. All preparation and submission costs are at the applicant’s https://www.grants.gov/ http://www.grants.gov/ mailto:support@grants.gov

NOFO No: 72038624RFA00004: Health Systems

Strengthening (HSS) Activity expense.

Please send any questions to the point of contact identified in Section D. The deadline for the questions is shown above.

Thank you for your interest in USAID programs.

Sincerely, Cheryl Hodge-Snead Agreement Officer USAID/India

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TABLE OF CONTENTS

SECTION A – PROGRAM DESCRIPTION

SECTION B – FEDERAL AWARD INFORMATION

SECTION C – ELIGIBILITY INFORMATION

SECTION D – CONCEPT PAPER SUBMISSION INFORMATION

SECTION E – CONCEPT PAPER REVIEW INFORMATION

SECTION F – FEDERAL AWARD ADMINISTRATION INFORMATION

SECTION G – FEDERAL AWARDING AGENCY CONTACTS

SECTION H – OTHER INFORMATION

ANNEXURES:

1. STANDARD PROVISIONS

2. PRELIMINARY GENDER EQUALITY AND SOCIAL INCLUSION ANALYSIS.

SECTION A: PROGRAM DESCRIPTION

END OF SECTION A

1. Program Framework

Purpose

India’s growth, dynamism and human capital provides unique opportunities for USAID engagement, unlike those found anywhere else in the world. It provides the agency with a roadmap of how to transition health programming in emerging economies, especially in ecologically fragile subregions, whilst continuing to promote the agency priorities of diversity, equity and inclusion, localization, using technology responsibly and engaging the private sector for development objectives.

This Health Systems Strengthening (HSS) activity aims to transform USAID’s traditional assistance to the Government of India (GoI) on cross-cutting health systems strengthening, signaling the transition in the US India partnership in health by strengthening platforms and institutions in the public and private sector to accelerate and scale innovative development approaches that are inclusive, sustainable and leverage digital health technologies. The purpose of the activity is to accelerate and scale up, and not incubate and seed, innovative approaches to increasing access and reducing out-of-pocket expenditure on healthcare in India. This activity will focus on vulnerable and marginalized communities in India, including those in urban areas, with the aim of expanding equitable access to comprehensive primary healthcare, strengthening the continuum of care, and advancing progress towards universal health coverage. This acceleration of innovative models and approaches, especially in the private sector, will be assisted by risk underwriting from the US

International Development Finance Corporation (DFC) and other bilateral/multilateral financial institutions.

This activity will move away from traditional models of assistance and focus on building and growing connections between government institutions and systems, existing platforms within the private sector, and networks of nonprofit entities and community-based organizations. The activity will also explore how experience and innovations from India can strengthen comprehensive primary healthcare (CPHC) around the world, adopting a platforms-based approach to take Indian healthcare innovations to other partner countries globally.

Problem Statement

In the post COVID-19 pandemic era, the central challenge, globally and in India, is ensuring inclusive public and private health systems are resilient, inclusive, and responsive, particularly at the foundational primary care level. The significant progress made towards the quality and reach of health services over recent years experienced significant backsliding during the pandemic in all areas exacerbating inequities. Over the coming years, climate related health challenges including extreme weather events shifting patterns of disease epidemiology have the potential to further curtail progress towards universal health coverage. Taken together, these demonstrate the need for a resilient health system capable and resourced to address existing challenges while managing new predictable and unpredictable ones. The government of India has allocated significant resources to improve health outcomes, but capacities of different states and municipal health authorities vary in their ability to deliver on these expenditure and budget utilization commitments.

Public healthcare access and services have expanded via the suite of initiatives offered under GoI’s

Ayushman Bharat program. Nevertheless, there remain gaps in geographic coverage, ease of access and acceptability especially by marginalized groups like tribal and LGBTQ communities, cost coverage, quality of care, and the integration of care between primary care “health and wellness centers” (HWC’s) and higher-level facilities. HWC’s are also limited in their ability to deliver care for non-communicable diseases that are the major causes of mortality among people aged below 50 years, mental health services, and preventive care (i.e. “wellness” services) to the communities which they serve. While the government rolls out the HWCs, they are looking at innovative models and technical assistance on how to integrate lateral programs of services delivery, include wellness, address mental health, and integrate community and environmental surveillance at the HWC level.

In urban areas, the government is actively looking for insights and understanding on how to address urban healthcare needs including wellness more effectively particularly leveraging digital health wherever feasible.

The private sector is significant in terms of health care delivery and health ecosystem. As compared to the government health system of approximately $30 billion, the private healthcare market in

India is approximately $300 billion and at 16% growth per year, is the fastest growing segment.

This private health sector also reaches out globally in terms of pharma, health tech, and manufacturing, while looking to expand into education and human resources for health (HRH). On the other hand, despite the global reach of the Indian private health sector, the consumer of healthcare domestically still struggles to get affordable and quality healthcare, particularly those that are vulnerable and marginalized.

Key Challenges

(a) The lasting effects of the pandemic on the health system

Given the global disruptions brought about by the COVID-19 pandemic, governments and investors have renewed their focus and investments in pandemic preparedness and response capacities. But this will be insufficient without sufficient focus on strengthening health systems and achieving universal health coverage1. During COVID-19, countries with robust primary healthcare systems saw minimal disruptions to other essential healthcare services2.

The disruptions caused by the pandemic resulted in an over 37% decline in hospitalizations in India and an almost doubling of out-of-pocket expenditure, despite having the world’s largest government funded health insurance program3. Primary healthcare was also severely impacted with most of the districts in India witnessing more than 50% decrease in antenatal care and child

1 Woodcock, A., Coronavirus: Boris Johnson calls for global pandemic early warning system. The Independent, Sept

26, 2020.

2 Blanc DC, Grundy J, Sodha SV, et al. Immunization programs to support primary health care and achieve universal health coverage. Vaccine. 2022 3 Garg S, Bebarta KK, Tripathi N. Household expenditure on non-Covid hospitalisation care during the Covid-19 pandemic and the role of financial protection policies in India. Arch Public Health. 2022;80(1):108.

https://doi.org/10.1186/s13690-022-00857-8 https://doi.org/10.1186/s13690-022-00857-8 immunization4. The estimates of excess deaths due to the pandemic in India varies from 2.8 to 5.2 million 5as estimated by the National Library of Medicine, and between 3.71 to 4.36 million as estimated by Lancet6. Most of these deaths occurred among people with comorbidities, especially with chronic and NCD conditions. Another paper found COVID-19 mortality not only among the elderly ages, but also identified a high impact of COVID-19 on the working population7. As the health system was overwhelmed by COVID-19 patients, it became difficult for other patients with acute or chronic ailments to access health services. Vulnerability was exacerbated, especially for women, children, the elderly (particularly with NCDs) and those with special needs8. All this calls for health systems strengthening with comprehensive primary healthcare linked with secondary and tertiary care through a seamless continuum of care, especially focused on reducing under-50 mortality in India.

(b) Shifting disease and demographics

Within noncommunicable diseases, mental health has emerged as a major concern with stress, anxiety, depression, insomnia, denial, anger and fear reported by people with existing mental illness, frontline workers, older people and also children9 and we are seeing links with mental health and traditional PHC treated conditions like MNCH, TB, HIV, reproductive health etc. Policy makers at the national and state levels as well as both government and private healthcare providers, both government and private, have strongly expressed the need to integrate care for mental health and other noncommunicable diseases across all levels of the health system10. In addition, with expanding human settlements, environmental changes and changes to food ecosystems, there has been a resurgence in infectious diseases originating from animals and birds. These challenges will require a one health system approach to responding to both infectious and non-communicable diseases.

India is now the world’s most populous country and the nation’s demographic structure is slowly evolving. While the bulge in the working-age population is expected to last till 2055, the proportion of the aging population in India is on the rise. As per the Longitudinal Ageing Study of India

4 Avula R, Nguyen PH, Ashok S, et al. Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: an observational study.

PLoS One. 2022 5 Banaji, M. and Gupta, A., 2022. Estimates of pandemic excess mortality in India based on civil registration data.

PLOS Global Public Health, 2(12), p.e0000803.

6 Wang, H., Paulson, K.R., Pease, S.A., Watson, S., Comfort, H., Zheng, P., Aravkin, A.Y., Bisignano, C., Barber, R.M., Alam, T. and Fuller, J.E., 2022. Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21. The Lancet, 399(10334), pp.1513-1536.

7 Azarudeen MJ, Aroskar K, Kurup KK, Dikid T, Chauhan H, Jain SK, Singh SK. Comparing COVID-19 mortality across selected states in India: The role of age structure. Clin Epidemiol Glob Health. 2021 Oct-Dec;12:100877. doi:

10.1016/j.cegh.2021.100877. Epub 2021 Oct 9. PMID: 34816056; PMCID: PMC8602842.

8 Khetrapal, S. and Bhatia, R., 2020. Impact of COVID-19 pandemic on health system & Sustainable Development

Goal 3. The Indian journal of medical research, 151(5), p.395.

9 Roy, A., Singh, A.K., Mishra, S., Chinnadurai, A., Mitra, A. and Bakshi, O., 2021. Mental health implications of

COVID-19 pandemic and its response in India. International Journal of Social Psychiatry, 67(5), pp.587-600.

10 As per stakeholder consultations carried out by the USAID design team and Health Office staff between July and

September 2023.

(LASI), from an elderly population of 104 million in 2011, the number will increase to 319 million by 2050.

(c) Challenges in urban health

Cities are the predominant mode of living in India. With continued urban growth, India will see rising inequities across a wide range of social and health dimensions. While social determinants of health are not uniquely urban, the size, density, diversity and complexity of India’s cities amplify their effects. Addressing the unique conditions affecting vulnerable urban populations such as slum communities, LGBTQ populations, and migrant and construction workers, and how those conditions impede access to healthcare services offers the greatest promise for reducing morbidity, mortality and disparities in health in urban areas and for improving the quality of life and well being. Although urban areas have high concentrations of secondary and tertiary care facilities, the primary healthcare, which is the bedrock of all healthcare, is fragmented and disorganized with disjointed governance/accountability. Also, the private sector dominates the healthcare provisioning in urban areas, which is costly, at secondary and tertiary level and largely informal at the primary level, with questionable quality of care.

(d) The healthcare ecosystem’s ability to deliver

Fiscal constraints and differential capacity across the multi-tier government service delivery system have led to gaps in service coverage for vulnerable and marginalized sections of rural and urban

India. Given these gaps, the variance in quality, cost and consumers of the private sector is significant, often leading to high transaction costs and risk for reaching the last mile with affordable services and products. This is where social enterprises have stepped in with their inclusive business models (IBMs), but they too are limited in scale because of inadequate funding and constraints posed by the legal environment11.

(e) Challenges to inclusivity

The barriers to accessing healthcare by vulnerable and marginalized populations also include non-medical obstacles like security, logistics, communications and socio-cultural issues, which need to be factored in the design of services and programs12. Also, special population groups have differential needs for services and the way those services are delivered. This is especially true for groups like LGBTQ, people living with HIV, coastal fishing communities, backyard farmers or animal rearers, mining and tea garden population, tribals, mobile populations, informal settlement dwellers, and differently abled groups13.

(f) Climate change and its effects on health and the healthcare ecosystem

Climate change intersects with health in many ways, including direct injury from climate mediated

11 Tinsley, E. and Agapitova, N., 2018. Reaching the last mile.

12 Osetek, J.D., 2018. The Last Mile: Removing Non-medical Obstacles in the Pursuit of Global Health Security

(Doctoral dissertation, George Mason University).

13 As per stakeholder consultations carried out by the USAID between July and September 2023.

extreme weather events and indirect changes to the epidemiology of infectious diseases; disrupting availability and access to quality services and medical products; and altering environmental and social determinants of health. Thus, it is imperative to put ample emphasis on building “climate smart” health systems (resilient to climate challenges and low carbon impact).

2. Theory Of Change

India’s G-20 presidency under the theme of ‘One Earth, One Family, One Future’ transformed

India’s posture as a significant player in a new world order. India now needs to ensure its steady economic growth whilst continuing to create opportunities and platforms to share its innovations and successes with the world. Unforeseen future shocks in health have the potential to undermine this growth at an individual, community and systemic level. Despite the country transitioning into a middle income country, low total health expenditure as percentage of GDP (less than 4% of GDP), very low government health expenditure as percentage of GDP (a little over 1% of GDP) and unchecked out of pocket expenditures (OOPE) on healthcare will compromise the continued economic growth of the country and force significant populations to be excluded from the growth trajectory. It is estimated that more than 50 million people fall into poverty because of high OOPE on healthcare, mostly due to spending on outpatient care, which also reduces their access to quality healthcare. Most people impacted by high OOPE belong to marginalized communities in vulnerable circumstances. A WHO report noted that OOPE on health services in

India has important implications for poverty levels and trends in India. Existing literature for India shows that OOP payments not only impoverish a large number of households, reduce access to timely and good quality healthcare, but also deepen poverty among already poor households.

The intended impact of the activity is to reduce under-50 mortality in India through a resilient health care system with the ability to provide universal health coverage. The activity will achieve this by focussing on the outcome of improved access and reduced out-pocket-expenditure (OOPE) on health care, especially for vulnerable and marginalized communities. The result-areas to achieve this outcome will include (i) increased access to integrated primary healthcare and wellness for marginalized groups including those in both rural and urban areas across their lifespan, (ii) assured continuity of care within and between primary, secondary and tertiary healthcare services, (iii) strengthened public-private integration to boost access, affordability and quality of care, (iv) increased supply side efficiency and demand-side financial risk cover, especially for primary health care, in public and private health systems, and (v) increased adaptation and mitigation of climate and environmental shocks affecting the health system. The activity will partner with the government, the private sector, civil society and community based organizations to assist them to test and scale up models and approaches to achieve the stated goals. The activity will not undertake routine service delivery, training and supervision functions, but rather will work with the government and private institutions, systems and networks to strengthen them to undertake those functions effectively. In the process, this activity will also identify promising approaches, technological solutions and business innovations that can lead to improved access and reduced

OOPE, and work with the government and private partners to absorb and scale those innovations.

Reducing OOPE on health will also drive the demand for healthcare and encourage supply chain innovations that improve access and inclusivity, reduce costs and enhance quality.

The theory of change for this activity is shown in the diagram below, which will be reviewed annually, and amended, if needed:

3. Partnering with other USAID projects

The HSS activity will work with ongoing and future USAID projects and activities, in the priority geographies, for better coordination and synergies. This will provide the opportunity to build on the

HSS work done during the pandemic and harness the opportunities created by surges in innovation and investments in health solutions, to make the health system better equipped to face known and unknown challenges whilst sharing successes with the world.

Coordination with other USAID projects and activities will include, but is not limited to, the following:

Impact Under-50 mortality in India reduced

Outcome A resilient health system provides universal health coverage to all

Goal Improved access and reduced out-of-pocket expenditure (OOPE) on quality healthcare in

Result 1:

Increased access to integrated primary healthcare and

Commu Digital

Governa

Cross-cutting

Components

Principles Progress InclusivLocaliz India-Ecosys

AcceleraPrivate Innovati

Result 2:

Assured continuity of care within and between primary, Result 3:

Strengthen ed public-private integration to boost access, Result 4:

supply side efficiency and demand-side

Result 5:

adaptation and mitigation of climate and

● Building on the primary healthcare support to the government provided by the NISHTHA project, especially in the northeastern and the central Indian states;

● Leveraging the network of secondary and tertiary health facilities, including laboratory networks under the RISE and Global Health Security (GHS) projects;

● Developing synergies with the climate and health activity to be undertaken under two local works activities;

● Working with USAID’s HIV projects to support the PLHIV community-led micro social enterprises;

● Assisting scale up of innovations supported under TB, GHS, MCH and FP projects including access to appropriate capital from financial market platforms like impact investment platforms and the Social Stock Exchange;

● Leveraging the SAMRIDH blended finance arrangement to help scale business and product solutions that can reduce OOPE on health and improve access to care, especially for marginalized and vulnerable communities;

● Working with USAID’s TB and HIV projects to accelerate coverage of out-patient care and comorbidities for TB and HIV patients.

● Developing synergies with USAID projects funded by Development Partnerships and

Innovations Office (DPIO) like the REVIVE project, and also programs on WASH, Education, Energy, and Climate supported by the General Development Office (GDO).

● For taking some of the innovations globally, partnering with activities of USAID’s Indo-

Pacific Office (IPO).

4. Priority Geographies

As this activity will prioritize acceleration, scale-up and institutionalization of innovative approaches, while leveraging public and private platforms and resources, it will build on innovative approaches and platforms already being developed and tested by existing USAID projects.

Working with these existing USAID projects and activities will necessitate working in the geographies where these activities are present. This will cover the northeastern states - particularly

Assam, the central Indian states of Odisha, Jharkhand, Madhya Pradesh, and Chhattisgarh, and urban areas including tier-2 and tier-3 towns and mega urban conglomerates like Mumbai, Delhi and Bengaluru. Prioritizing these geographies does not mean that the HSS activity should undertake routine health systems activities in these states, but rather that it should source innovative approaches showing promise in these states and leverage government and private sector institutions and platforms to take them to scale regionally and nationally, while sharing relevant knowledge and resources for how to scale these approaches with a global audience.

5. Outcome, Results and Key Deliverables

The activity will use a multidisciplinary approach to larger health ecosystem issues to identify, test and scale tailormade climate resilient and adaptive healthcare models and approaches aimed at increased quality service uptake and reduced OOPE, especially for vulnerable and marginalized communities across urban, rural, and tribal areas. Due to the multidisciplinary nature of the activity, it will require multiple implementing partners, either as a consortium or as sub contracted agencies, with specialized skill expertise across domains.

This activity will support healthcare delivery models, approaches and platforms that already exist but need an additional nudge to transition to scale, either within government programs or as sustainable inclusive business models. While a period of testing of approaches and models is expected, the activity will mainly focus on bringing them to scale and developing the capacity of the final adopter of the approaches and models (e.g. government, private sector, or the community) to assume ownership.

Expected Impact, Outcome, Goal and Results:

The activity identifies the primary development challenge as a reduction in under-50 mortality through a resilient health system that is able to deliver universal health coverage while responding to emerging climate and health shocks. The reduction in under-50 mortality will be achieved by helping build a resilient health system in India that is prepared for future climate and health challenges, while accommodating the special needs of the vulnerable and marginalized population segments in India. The purpose of the activity is to identify, test and scale up sustainable, easily accessible, affordable and quality healthcare models through the institutions, platforms and networks of the national and state governments, city administrations, private sector and community based organizations. Through this, the activity aims at achieving the outcome of increased health service uptake and reduced OOPE, especially for the vulnerable and marginalized groups.

The expected impact, outcomes, key results, and illustrative activities are given below.

Impact : Under-50 mortality in India reduced

Outcome: A resilient health system that provides universal health coverage

Goal: Improved access and reduced out-of-pocket on quality healthcare in India, especially for vulnerable and marginalized communities

Result 1: Increased access to integrated primary healthcare and wellness for marginalized groups including those in both rural and urban areas across their lifespan. (Level of effort - 30%)

Illustrative activities:

● Demonstrate and scale up innovative, comprehensive, quality primary healthcare models and platforms, including networked care models, that reflect the needs of the variety of users and suppliers of primary health care, including those that focus on digitization and aggregation of services and processes.

● Expand public health surveillance for disease prevention and response by integrating environmental data, especially in urban areas within the primary healthcare system.

Result 2: Assured continuity of care within and between primary, secondary and tertiary healthcare services (Level of effort - 20%)

Illustrative activities:

● Deploy innovative approaches (including digital technology) to boost quality, empower both patients and health workers, and integrate care across the healthcare continuum.

● Leverage the network of public and private secondary and tertiary healthcare facilities, including the network of laboratories.

● Demonstrate quality integrated health services including systems for infection prevention and control and addressing AMR

● Building a resilient health system for pandemic preparedness such as surge capacities, resilient supply chain, strengthening lab and emerging priorities of Government of India for pandemic preparedness.

Result 3: Strengthen public-private integration to boost access, affordability and quality of care

(Level of effort - 20%)

Illustrative activities:

● Strengthen public-private integration to boost access, affordability, and quality of care (e.g public-private partnership management, strategic purchasing etc), especially for “primary impact collaboratives” and AMR alliances.

● Scale market based solutions, including support for commercial viability and market shaping, to address persistent health challenges (e.g. social enterprises, inclusive/affordable business models, etc.).

● Partnering with medical and business associations, CSR platforms, in collaboration with local government, for primary healthcare collaborations focussed on leveraging resources and innovations.

● Support ongoing platforms/efforts engaged in training and certification of private primary care facilities and linkages to affordable drugs and diagnostics.

Result 4: Increased supply side efficiency and demand-side financial risk cover, especially for primary health care, in public and private health systems. (Level of effort - 20%)

Illustrative activities:

● Include preventive and out-patient care in government and private health insurance programs.

● Help integrate national health programs (like the HIV, TB, AMR program) in publicly subsidized or privately financed insurance programs, including adoption of disease management protocols and quality standards.

● Strengthen public financial management, especially the municipal finance and governance, to finance comprehensive and integrated healthcare.

● Support for resource mobilization, including risk underwriting by the Development Finance

Corporation, for public and private health systems from diverse and underutilized sources

(e.g. diaspora, social stock exchange, district mineral funds, municipal bonds, etc.)

● Leverage innovative platforms (like social stock exchange, GIFT city platform, social impact bonds, multilateral blended finance platforms) to accelerate access and impact towards integrated quality and affordable healthcare services.

Result 5: Increased adaptation and mitigation of climate and environmental shocks affecting the health system (Level of effort - 10%)

Illustrative activities:

● Strengthen health facilities and healthcare supply chains to respond to climate and health shock

● Scale up business models for healthcare waste management, renewable energy, green health facilities and green supply chain in public and private health systems

For the above mentioned results, the planned deliverables of the activity are:

1. Integrated, high quality, and affordable, primary health care models, with assured continuum of care, scaled up by the central and state governments and the city administrations in India. These approaches should accommodate the special needs of the vulnerable and marginalized groups, especially in urban areas.

2. Inclusive business models addressing health sector gaps scaled up by the private sector.

3. Greater partnership and integration between the public and private health sectors.

4. Innovative financing platforms and approaches leveraged for increased scaling up of healthcare innovations, including community level innovations.

5. Models of expanded healthcare financial risk coverage (including outpatient care and wellness) adopted and scaled by the public and private sector.

6. Promising climate resilient models and approaches scaled up in public and private health facilities and supply chain.

7. Promising Indian integrated healthcare approaches, business models, financing, and private sector innovations adopted by third country governments and private sector players.

To deliver the above mentioned deliverables and results, the activity will work across the following cross cutting components:

(i) Community engagement with focus on vulnerable populations

(ii) Governance and accountability, especially at state, district and municipal level

(iii) Digital health

(iv) Private sector engagement - platform based engagements

(v) Innovative financing - for government, nonprofit, healthcare micro enterprises, and insurance

(vi) Acceleration and scale up - going beyond testing and incubation and supporting adoption, absorption and scale up by government and private sector

6. Guiding Principles

This activity supports USAID partnership with India to achieve shared global priorities, including

G20 objectives related to pandemic preparedness, medical countermeasures, digital public goods, climate change mitigation and adaptation, universal health coverage, and innovative financing. This activity will strengthen the health system to progress towards universal health coverage, addressing impoverishment due to high out-of-pocket expenses on healthcare, while responding to emerging threats including emerging infectious diseases. This activity will also support the health system and community resilience to challenges related to climate change. In addition, the activity will support collaboration and integration between both public and private sector health stakeholders. It will mobilize new resources for public health priorities through innovative private sector engagements;

It will also strategically leverage BMGF, GFATM, World Bank, ADB and other donor resources received by the Indian government for climate and health actions.

The activity will be guided by the following principles:

1. Localisation to ensure programmatic and financial sustainability: USAID envisions expanding the share of its programs that are locally led, in which a diverse group of local actors define priorities, design projects, drive implementation, measure and evaluate results, and more fully own and sustain efforts to save lives, reduce poverty, strengthen democratic governance, reduce corruption, address climate change, work to prevent conflicts, respond to global pandemics, and emerge from humanitarian crises. Localization principles must also inform our engagement beyond our projects: our convenings, the expertise we seek, our policy reform dialogues, and all the ways we engage in development.

2. Inclusive and participatory: USAID will center its actions in the context of the diverse communities in which we work and will engage local, marginalized, and underrepresented groups as agents of change, especially in urban areas.

3. Ecosystem approach: While the total central and state government annual health budget is approximately $35 billion, the total healthcare segment in India is a $300 billion industry, including private healthcare industry, medical technologies and equipment, pharmaceuticals, health insurance, home based healthcare, etc. This overall health segment of the Indian economy is growing at approximately 16% per year, making it the fastest growing segment. It is also the largest employment generating segment in India. This makes it imperative to approach health systems strengthening and scaling up innovative approaches by developing synergies and linkages with platforms and institutions across the healthcare ecosystem.

4. India for the World: Given India’s size, global reach (e.g. diaspora and trade relationships), and vibrant innovation ecosystem, solutions to address global health system challenges can be incubated in India and adapted for use across the world. The activity will adopt a platforms-based approach to take Indian healthcare innovations to other partner countries globally.

5. Progress Beyond Programs: Drive progress in ways that surpass the confines of the

USAID program budgets and related scope of implemented activities. This includes embracing new, inclusive and ambitious partnerships.

The activity will address systemic barriers, such as governance, financing, provider and community behaviors, etc. This activity will operate in close partnership with national and state governments, networks of private health facilities, and private sector (like pharmaceutical industry and medical device manufacturers). Digital health solutions will be compliant with the India Health Stack so as to be interoperable across different levels of the health system.

7. Activity Parameters

a) Target Beneficiaries - The scaled health system approaches and models will target the vulnerable populations in urban and rural areas, including the tribal communities, communities residing in ecologically vulnerable areas like hills, forests, cyclone prone coastal areas, the slum communities, LGBTQ populations, migrant and construction workers in selected states and cities/towns as mentioned in section 4 above.

b) Gender and Social Inclusion - The activity will prioritize scaling up high-quality, comprehensive, low cost, home-based or near-to-home healthcare and wellness models and approaches, specifically targeted at women, and other underrepresented and underprivileged communities. It will also work with city and state governments for strengthening public-private partnerships and strategic purchasing models for ensuring higher quality and affordable healthcare, especially for comprehensive primary healthcare, targeted at women, people with disability and other marginalized populations. The activity will test models of financial risk protection especially targeted at special health needs of women and other marginalized communities, both as publicly subsidized models as well as low-cost business models. In addition, this activity will prioritize providing support to public and private primary and secondary level facilities that are accessed more by women, people with disabilities and other marginalized communities, for increased adoption of climate resilient facility design and equipment and supplies.

c) Leverage - We expect at least 1:1 leverage in cash and preferably 1:2 to 1:5 leverage

(including cash and in-kind) from the implementing partners, with the additional funds leveraged from government programs, quasi government entities, private sector and financial markets. This implies USAID will fund up to 50% of the indicated TEC.

8. Monitoring, Evaluation and Learning

The goal of reduced OOPE and increased access and utilization of comprehensive primary healthcare services will be obtained from large scale public databases like National Family Health

Survey (NFHS) and National Sample Surveys (NSS), the progress on results will be tracked quarterly and annually from Project Management Information Systems (PMIS). Also, given the

1+2+2 year break up of the activity period, progress feedback will be looped-in to plan for next stages in the first and third year.

A Continuous Learning and Adaptation (CLA) approach will be taken to develop the detailed MEL plan. Effort will be made to move away from the traditional 2Rs approach to MEL (measuring

Resource inputs and Results) and, instead, adopt a 5Rs approach to MEL (tracking Resources, Rules, Roles, Relationships and Results), using mixed-methods approaches. This will be based on the “5Rs Framework in the Program Cycle”14 published by USAID Learning Lab, recognizing the pathway to results following complex adaptive systems in the context of health systems strengthening. The activity will also undertake annual review of the “theory of change” to revalidate the assumptions and results pathways throughout the activity duration.

A detailed MEL framework will be prepared after this Program Description is finalized in the co-design phase.

[END OF SECTION A]

14 Technical Note on “5Rs Framework in the Program Cycle”, version 2.1, by USAID Learning Labs; October 2016 accessed at https://usaidlearninglab.org/system/files/resource/files/5rs_techncial_note_ver_2_1_final.pdf on June 6, https://usaidlearninglab.org/system/files/resource/files/5rs_techncial_note_ver_2_1_final.pdf

SECTION B: FEDERAL AWARD INFORMATION

B.1 Estimate of Funds Available and Number of Awards Contemplated

USAID intends to award one (1) Fixed Amount Cooperative Agreement with option for renewal period pursuant to this NOFO, however, USAID reserves the right to negotiate more than one award, or no awards, pursuant to this NOFO.

Subject to funding availability, USAID intends to provide up to $20,000,000 in total USAID funding over a five year period over two phases.

Base Period (Project Years 1 to 2): Initial award up to $6,000,000. Renewal Period (Project Years 3 to 5): Budgeted at $14,000,000. Final amount to be determined in the programmatic review and may be lower or higher depending on the situation.

Actual funding amounts are subject to availability of funds. USAID reserves the right to fund any or none of the applications submitted.

B.2 Expected Performance Indicators, Targets, Baseline Data, and Data Collection

USAID/India intends for the activity to be subject to rigorous performance monitoring to (a) ensure that milestones are being met, and (b) inform activity management if, and when, course corrections may be necessary. The recipient should also conduct several periodic reviews and analyses of the performance to better understand certain aspects and implementation issues within the award’s domain.

Performance monitoring parameters will be included by the Applicant while designing their technical approach or milestones. USAID may conduct additional monitoring and performance assessment through external contract(s). A detailed Activity monitoring plan will be developed soon after the initiation of the project with detailed baseline information and will include appropriate targets and indicators to measure the progress based on the expected objectives of the activity as detailed in the

Program Description or milestones.

USAID/India recognizes that development efforts yield positive change more quickly if they are coordinated and collaborative, test promising new approaches in a continuous search for improvement, and build on what works, while eliminating what does not. The recipient must therefore implement a Collaborating, Learning and Adaptation (CLA) approach to continuously assess the activity’s causal pathways, target outcomes, and adjust the interventions and approach as necessary to yield the most effective course of action.

B.3 Start Date and Period of Performance for Federal Award

The anticipated total period of performance is up to five years. The estimated start date will be upon the issuance of the awards by the Agreement Officer.

B.4 Award Renewal

The HSS activity will be a milestone-based fixed amount cooperative agreement divided into two performance periods, the Base Period (project years 2) and the Renewal Period (project years 3). The initial duration of the award will be two years (Base Period), with an option to renew for another 3 years (Renewal Period). Renewal of the award is conditioned upon the availability of funds;

satisfactory progress toward meeting the award objectives; submission of required reports; and compliance with the terms and conditions of the award, including the conditions for renewal.

a. Timing of Renewals

USAID will conduct the mid-term and final programmatic review of the Base period activities at 12 months and 20 months after the award respectively. Based on the successful achievement of the following renewal conditions USAID will invite the applicant to submit the detailed application for the Renewal period. Below are the Renewal period conditions:

Subject to availability of funds, USAID will invite the applicant to submit a detailed application to continue implementation of the Renewal period activities.

● USAID will assess the applicant’s progress towards meeting the award objectives based on the results of the final programmatic review of the Base period of implementation.

● USAID will also assess and take into consideration the timely submission of the required program reports both technical and financial.

● USAID will also review the applicant’s compliance with the terms and conditions of the award including the renewal conditions including the required risk-assessment requirements.

● As part of the re-application process, if required, USAID may revise the award and define further activities within the general program description of the award.

Based on the successful achievement of the renewal conditions as stated above, the applicant must reapply for the Renewal period activities at least three months prior to the completion of the Base period of implementation.

If the Renewal period is executed, the start date of the renewal period will be concurrent with the expiration date of the Base period to prevent a break in the activities or funding. In the event the award is not renewed, USAID will inform the recipient in a timely manner and provide sufficient time to complete the program activities prior to the end date of the initial award period.

b. Renewal Application Instructions

The Recipient’s reapplication will include:

● Proposed Milestones for the Renewal Period

● Detailed Budget to complete the proposed Milestones, along with a Budget Narrative

● Technical Approach for the Renewal Period

● Organizational and Staffing Plan for Renewal Period

In addition, the recipient will resubmit a new SF-424 and a new set of certifications, assurances, representations, and other statements (see 303.3.8, Pre-Award Certifications, Assurances, Representations, and Other Statements of the Recipient and Pre-Award Terms), along with the request for renewal. The AO may renew the award through a modification for the renewal period (yr.

3-5).

c. Criteria for Renewal

USAID will evaluate the Renewal re-application based on the following:

● Recipient’s satisfactory performance towards meeting the Base award objectives;

● Renewal award’s activity’s relevance to Agency objectives;

● The renewal will support either the same work, or work that is within the programmatic activities of the Base award or is closely related to the Base award programmatic activities;

● The renewal supports the same long-term goal as the Base award, with new specific targets, milestones, outputs, or indicators; and

● Recipient continues to meet the required risk-assessment requirements.

If the Renewal period is executed, the start date of the renewal period will be concurrent with the expiration date of the Base award to prevent a break in the activities or funding. In the event the award is not renewed, USAID will inform the recipient in a timely manner and provide sufficient time to complete the program activities prior to the end date of the award Base Period.

NOTE: The renewal process will be initiated only with the implementing partner, who was determined the most successful applicant and received the initial award.

B.5 Substantial Involvement

In accordance with ADS 303.3.11, USAID/India shall be substantially involved during the implementation of this award, through the Agreement Officer's Representative (AOR)’s approval of the following:

a. Approval of recipient’s Annual Implementation Plans including milestone plans. The

Annual Implementation Plan will act as a living document. It will provide specific planning for the year. A quarterly review of the plan will take place with the AOR. The AOR will participate in the quarterly review and any updates to the Annual Implementation Plan will be documented in email to the AOR along with the submission of the updated plan. The Annual Implementation Plan will detail specific tasks/activities per milestone, with an associated schedule for completion in accordance with the milestone schedule.

b. Recipient to obtain AOR’s approval prior to hiring the key personnel on the following

Key Personnel Positions, to achieve award’s objectives:

1. Project Director

2. Monitoring, Evaluation & Learning (MEL) Lead

3. Health Systems Lead

4. Community Lead

5. Private Sector and Financing Lead

c. Collaboration with USAID to facilitate coordination and communication with key stakeholders:

Joint collaboration and engagement with national and global technical working groups and other key stakeholders; periodic collaboration with USAID to ensure global and national best practices on HSS monitoring are followed.

NOTE: This Substantial Involvement section is subject to change following the Co-Creation

Workshop and submission of the Final Application Phase.

B.6 Authorized Geographic Code

The authorized Geographic Code for the procurement of commodities and services under this program is 937, which is defined as the United States, the recipient country, and developing countries other than advanced developing countries, but excluding any country that is a prohibited source.

There are currently no prohibited source countries, but the list is updated regularly and can be found here:

https://www.usaid.gov/sites/default/files/documents/1864/310mac.pdf

B.7 Nature of the Relationship between USAID and the Recipient

The principal purpose of the relationship with the Recipient and under the subject program is to transfer funds to accomplish a public purpose of the HSS activity which is authorized by Federal

Statute. The Recipient is responsible for ensuring the achievement of the program objectives and the efficient and effective administration of the award through the application of sound management practices. The Successful Recipient assumes responsibility for administering Federal funds in a manner consistent with underlying agreements, program objectives, and the terms and conditions of the Federal award.

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