NOFO NO. 72062024RFA00009- USAID PHIP.pdf

ISSUE DATE: October 09, 2024, 4:30 PM WAT

PRE-APPLICATION CONFERENCE:

October 23, 2024, in Abuja, Nigeria; please see below for registration details

DEADLINE FOR QUESTIONS: October 25, 2024, 4:30 PM WAT

CLOSING DATE AND TIME: November 15, 2024, 4:30 PM WAT

PROGRAM TITLE:

USAID Primary Health Care Improvement Program (UPHIP)

SUBJECT: Notice of Funding Opportunity (NOFO) Number: 72062024RFA00009

Dear Interested Parties, The United States Agency for International Development (USAID) seeks concepts from qualified entities to implement the USAID Primary Health Care Improvement Program. Eligibility for this award is restricted to local Nigerian organizations.

USAID intends to issue one or more awards 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 applying are encouraged to read this NOFO thoroughly to understand the type of program sought, application submission requirements and selection process.

USAID anticipates that a pre-application conference will be held in Abuja, Nigeria on or about October 23, 2024. The pre-application conference will be open to no more than 150 participants. Participants will be invited on a “first come, first served” basis from their date of registration. Applicants may register no more than two participants per organization. If you are interested in attending this pre-application conference, please respond using this link. Details regarding the final date and location will be provided to those that register.

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.

Questions regarding this funding opportunity must be sent electronically to abujasolicitations@usaid.gov. The deadline for receipt of questions is shown above. Responses to questions received prior to the deadline will be furnished to all potential applicants through an amendment to NOFO posted to www.grants.gov.

https://docs.google.com/forms/d/e/1FAIpQLSeA7LBNeSQQz-CwO7i8jiKd3aSSj7MkhVSVGktJOUgvkEViAg/viewform about:blank about:blank

USAID/Nigeria Notice of Funding Opportunity No. 72062024RFA000009 USAID Primary Health Care Improvement Program (UPHIP)

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, Marva M. Butler Agreement Officer USAID/Nigeria

TABLE OF CONTENTS

SECTION A: FEDERAL AWARD INFORMATION

SECTION B: ELIGIBILITY

SECTION C: PROGRAM DESCRIPTION

SECTION D: APPLICATION CONTENT AND FORMAT

SECTION E: APPLICATION REVIEW INFORMATION

SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION

SECTION G: FEDERAL AWARDING AGENCY CONTACT(S)

SECTION H: OTHER INFORMATION

SECTION A: FEDERAL AWARD INFORMATION

1. Estimated of Funds Available and Number of Awards Contemplated

USAID intends to issue one or more renewal cooperative agreement awards under this notice of funding opportunity.

A renewal award allows an award to adapt, within the five-year maximum period of performance, to changing contexts, lessons learned during implementation, and performance by related activities within a project that affect the overall effectiveness of the initial award. A renewal award requires the recipient to re-apply at a specified point during performance to continue the award. The initial period of performance awards is three years, with the possibility to renew for an additional two years.

Subject to funding availability, USAID intends to provide up to $40,000,000 in total USAID funding for one or more renewal awards over a five-year period, across two phases (initial and renewal).

Initial Period of Performance (Project Year 1- 3): Up to $24,000,000.

Renewal Period of Performance (Project Year 4-5): Budgeted up to $16,000,000; however, the final amount to be determined in the programmatic review.

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

2. Start Date and Period of Performance for Federal Awards

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

3. Award Renewal

The UPHIP award will be a cooperative agreement divided into two performance periods, the Initial Period (Project Years 1-3) and the Renewal Period (Project Years 4-5).

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.

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.

Performance Indicators for Renewal

There will be an assessment to determine if this award will continue beyond the initial three-year period and be considered for renewal for up to an additional two-year period. USAID will externally and objectively verify achievement of key results. Below are some illustrative examples that will be considered:

● At least 20% increase in overall capacity assessment scores from baseline to midline and a minimum of an additional ten percent increase in overall capacity assessment scores from mid-line to end-line capacity assessments of health facilities. This measurement will be verified by the MOH and USAID.

● Increased accuracy of malaria testing with RDTs or microscopy (malaria test rate) and treated.

● Retention of 80% of the ANC 1 attendees through labor/delivery and postnatal care.

● Decreased facility maternal mortality ratio by 40% by the end of the award

● Decreased average per capita out-of-pocket expenditure by 50% in implementation areas

● Increased fully immunized children by about 40% of the baseline

Please note the above are illustrative and will be negotiated with the successful applicant(s) after the baseline has been determined. This measurement will be verified through a third-party providing support and verification. The applicant will work closely with an external partner, to be hired by USAID, during the annual performance audits to verify achievement for the above results.

4. Substantial Involvement

As per ADS 303.3.11, USAID/Nigeria will remain substantially during award implementation.

Substantial involvement under the resulting awards will include the following:

(a) The Agency’s approval of the recipient’s implementation plans during performance. USAID requires approval of implementation plans annually to incorporate changed contexts or new information required in the activity, USAID may consider changes to an implementation plan.

These plans include:

a. Annual Work Plans

b. Annual Monitoring and Evaluation Plan

(b) Approval of Key Personnel. The recipient must obtain prior USAID approval of Key Personnel positions, which are deemed essential to the successful implementation of the activity. USAID reserves the right to determine the relevance of education and experience for all Key Personnel positions.

(c) The Agency’s ability to immediately halt an activity if the recipient does not meet identified performance targets.

(d) The Agency’s review and approval of substantive provisions of proposed subawards or contracts. The Recipient must obtain Agreement Officer approval prior to the issuance of any subawards or the transfer or contracting out of any work under an award.

(e) USAID and recipient collaboration or joint participation, including USAID involvement as a member of advisory committees, when the recipient’s successful accomplishment of program objectives would benefit from USAID’s technical knowledge. This includes USAID participation in specific meetings with partners, donors and the GON.

(f) Agency monitoring to permit specific kinds of direction or redirection of the work because of the interrelationships with other USAID or donor programs, alignment with U.S. Foreign Policy objectives, and USAID/Nigeria strategy.

(g) Highly prescriptive Agency requirements established prior to award that limit the recipient’s discretion with respect to the scope of services offered, organizational structure, staffing, mode of operation, and other management processes, coupled with close monitoring or operational involvement during performance over and above the normal exercise of Federal stewardship responsibilities to ensure compliance with these requirements.

5. Authorized Geographic Code

The geographic code for the procurement of commodities and services under this program is 937, 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. Procurement of vehicles and pharmaceuticals and other restricted commodities are subject to the limitations in 22 CFR 228, ADS 312, and ADS 310 and may require a waiver or Agreement Officer’s approval.

For accurate identification of prohibited sources, please refer to 22 CFR 228 and Automated Directive System (ADS) 310 entitled “Source and Nationality Requirements for Procurement of Commodities and Services Financed by USAID.

6. Nature of the Relationship between USAID and the Recipient

The principal purpose of the relationship with the Recipients and under the subject program is to transfer funds to accomplish a public purpose of support or stimulation of the USAID Primary Health Care Improvement Program (UPHIP) which is authorized by Federal statute. The successful Recipient will be 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 Recipient will assume responsibility for administering Federal funds in a manner consistent with underlying agreements, program objectives, and the terms and conditions of the Federal award.

[END OF SECTION A]

SECTION B: ELIGIBILITY

1. Eligible Applicants

Eligibility for this NOFO is restricted to local Nigerian organizations.

USAID defines a “local entity” as an individual, a corporation, a nonprofit organization, or another body of persons that:

(1) Is legally organized under the laws of Nigeria;

(2) Has as its principal place of business or operations in Nigeria; and

(3) Is

a. majority owned (51%) by individuals who are citizens or lawful permanent residents of Nigeria; and

b. managed by a governing body the majority of who are citizens or lawful permanent residents of the country receiving assistance.

For purposes of this definition, ‘majority owned’ and ‘managed by’ include, without limitation, beneficiary interests and the power, either directly or indirectly, whether exercised or exercisable, to control the election, appointment, or tenure of the organization's managers or a majority of the organization's governing body by any means.

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

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

2. Other

An organization may submit only one (1) concept paper under this notice of funding opportunity.

However, organizations participating as a member of a consortium may elect to participate in another consortium under a different concept paper.

In support of the Agency’s interest in fostering a larger assistance base and expanding the number and sustainability of development partners, USAID encourages applications from potential new and underutilized implementing partners who may not have previously received financial assistance from USAID. Any resultant award to a new organization may require a pre-award review of the organizations as part of a “risk assessment” of a potential recipient.

New partner is defined as an organization that has never received direct or indirect awards from USAID. An underutilized partner is defined by the Agency as an organization that has received less than $25 million in direct or indirect awards from USAID over the past five years. The five years is relative to when the organization is applying to a USAID procurement/funding opportunity.

Non-U.S. Organization Pre-award Survey Guidelines and Support is available in the following link:

https://www.usaid.gov/sites/default/files/documents/303mak.pdf.

[END OF SECTION B]

https://www.usaid.gov/sites/default/files/documents/303mak.pdf

SECTION C: PROGRAM DESCRIPTION

Title: USAID Primary Health Care Improvement Program (UPHIP)

1. Introduction

The United States Agency for International Development in Nigeria (USAID/Nigeria) seeks applications from qualified Nigerian Organizations to build a more effective, resilient, and responsive primary healthcare system that can adapt to the changing needs of the Nigerian population through the “USAID USAID Primary Health Care Improvement Program (UPHIP)." UPHIP will support the Government of Nigeria (GON)'s ambitious Nigeria Health Sector Renewal Investment Plan.

Goals

● Through awards under this program description, USAID/Nigeria will support the country's goal of moving to a sector-wide approach by supporting one country's plan, budget, and report and to transform the health sector in Nigeria to provide a healthier, more productive future for all Nigerians.

● Address supply and demand side issues among selected primary and secondary referral facilities to develop networks of service providers and care and reduce disease-specific siloes so that care is continuous and well-coordinated across patient lifespans.

USAID intends to issue one or more awards that will collaborate with USAID/Nigeria’s other activities that focus on the areas of human resources for health, healthcare financing (including support for health insurance), community health, social and behavior change communication, data use, and strengthening health information. These other awards will be co-located within the same geographies as UPHIP to maximize and amplify results. USAID/Nigeria's support is expected to build on GoN domestic financing, past USAID development programs and complement technical assistance from other development partners.

The UPHIP emphasizes achievement of measurable, high-quality, and cost-effective results to support the objectives and priorities outlined in this Program Description (PD). Additionally, UPHIP places a premium focus on strong financial management, and evidence-based learning and adaptation fueled by cost-efficiency, innovation, use of appropriate technology, and partnership with new and underutilized local partners, including those from the private sector.

UPHIP will build upon Nigeria's gains made from USAID and other donor’s investments in the delivery, utilization, and quality of Reproductive, Maternal, Newborn, and Child Health (RMNCH), malaria and global health security services.

2. Development Challenges

Despite some progress, Nigeria still faces significant challenges to improve reproductive, maternal, newborn, child and adolescent health and to control and manage malaria. Nigeria has one of the highest maternal and child mortality rates in the world. The lifetime risk of a Nigerian woman dying during pregnancy, childbirth, postpartum, or post-abortion is 1 in 22, in contrast to the lifetime risk in developed countries estimated at 1 in 4900. A combination of gaps in access to care and failures to adequately utilize available health services limit utilization. There are also critical gaps in quality which leads to incomplete or incorrect care. The Lancet Commission for Health Systems1 (2018) defines a high-quality health system as one that “optimizes health in a given context by consistently delivering care that improves or maintains health, being valued and trusted by all people, and responding to changing population needs.”

Ultimately, socioeconomic factors and negative experiences with the healthcare system impact Nigerians' utilization of services. While not exhaustive, socioeconomic factors include low levels of education, financial constraints, long distances to health facilities, and the burden of domestic chores.

These factors limit time and ability to seek care, and for some, limit the ability to appreciate the importance of timely health care seeking or translate knowledge into healthy behaviors and practices.

Additionally, gender imbalances and cultural norms constrain decision-making by adolescents and young adults, and by female clients and caretakers to seek timely care either for themselves or children under their care. These social factors combine to inhibit Nigerians' ability to maximize utility of available health care services, leading to outcomes such as utilization of alternative services like religious homes and traditional birth attendants, non-compliance with antenatal care appointments, low utilization of family planning methods, poor management of severe malaria and inconsistent use of insecticide-treated mosquito nets.

The quality of care is impacted by a range of factors, such as inadequate human resource for health (HRH) and absenteeism especially in hard to reach and security compromised areas, absenteeism, limited or variable skills among providers, which in many cases results in delayed or poor-quality care that negatively impacts health outcomes and healthcare-seeking behavior. Waiting times of up to 6 hours have been reported in some facilities. Provider skills, in turn, are affected by a high attrition rate among healthcare workers (partly due to a lack of motivation for various reasons, including inadequate remuneration). Healthcare providers also may need more access to necessary medical equipment to provide quality health care. Additionally, there is inadequate capacity for health services organization and management at the level of the local government authority, which ultimately leads to inefficiencies and a less-than-ideal working environment.

2.1. Commodities and Life-Saving Equipment

Consistent access to life saving drugs and functional equipment impacts service utilization. Failures linked to logistics and distribution are more common than commodity stock outs from the central medical stores, where all medicines are received, housed, and distributed. In addition, life-saving equipment is routinely absent or poorly maintained, because of limited training and availability of qualified repair and biomedical technicians. Despite MOH specifications for equipment, a variety of drugs and equipment are brought by partners into the country leading to problems of equipment integration, interoperability and sustainability.

2.2 Monitoring and evaluation - use of data for Health Care decision-making

Monitoring and evaluation are key activity management components, which track progress in implementation and achievement against activity objectives and provide data for decision-making.

1 High-quality health systems in the Sustainable Development Goals era: time for a revolution. Kruk, et al. Lancet Glob Health 2018; 6: e1196–252

Monitoring and evaluation (M&E) are a critical component of the Nigeria health sector plan, it helps to ensure that healthcare programs and services are effective, efficient, and responsive to the health needs of communities. Over the years, the government has continued to strive to improve the accuracy, completeness, consistency and reliability of health program datasets for informed decision making.

Hence, the award Recipient will build state, local government authority (LGA), ward, and health facility capacity to track and use key RMNCAH, nutrition, malaria and global health security indicators over time, primarily using District Health Information System (DHIS)-2 and other systems, to examine progress towards national, state, and program goals. The Recipient will also provide continuous technical support to frontline health workers2, health facilities, LGA, ward, and local government management teams on data management and data use for decision-making, including data quality assurance and analysis.

2.3. Gender and gender-based violence

Gender integration and gender-based violence (GBV) prevention and response are priority areas for all USAID activities and programs, including health. Similarly, the GON continues to champion gender mainstreaming efforts in all sectors by developing, implementing, and reporting on the required gender strategies. The GON outlines the gender-related priorities to be achieved in the various sectors, including the integration of a package of GBV services in the healthcare system. Despite the progress, gender issues and GBV still exist in Nigeria. A USAID/Nigeria gender and social inclusion analysis carried out in 2023 revealed that despite strong gender-sensitive policies implemented by the GON, gender disparities still pose barriers to the achievement of desired health outcomes. Findings include lack of male engagement in caregiving and domestic work; high illiteracy rate for women, limited female involvement in decision-making and control of household resources; social norms and stigma that are a significant barrier to accessing health services coupled with gaps in training and sensitization of health care providers, which cause further marginalization of vulnerable populations.

In general, youth face challenges in accessing health care due to limited knowledge about reproductive health and may experience gatekeeping that prevents access such as younger females between 18-29 (especially unmarried) are often barred from accessing sexual and reproductive health services (including HIV testing) and health providers tend to discriminate against younger males ages 18-29 for being male and give preferential treatment to women and girls. Health care is a key avenue for identifying and addressing GBV incidents, as health providers are often the first–and sometimes the only–point of contact for survivors. GBV can lead to health issues that require specific medical care, such as testing for HIV and other sexually transmitted diseases, pre- and post-exposure prophylaxis, additional antiretroviral medications for individuals who are HIV-positive, and emergency contraceptives. Despite the high prevalence of GBV in Nigeria, GBV is underreported, especially by women and girls with disabilities and men and boys, who may feel ashamed to report.

2.4 Lessons Learned from previous USAID programing

● Facility Saturation: Historical USAID support for PHC strengthening was targeted to BHCPF facilities/1 PHC per ward model only, which was not enough saturation of support to show change.

2 Includes all staff working at primary health care centers and secondary hospitals. This also includes all community health workers attached to these facilities.

● Technical Support Models: Previous efforts have included a “blanket/common” approach to technical assistance or support that is not sensitive to geographic differences and data-driven for technical assistance differentiated by facility.

● Static Support: Technical assistance and support were provided to the same facilities over a three-to-five-year period. The below tiered approaches are simply illustrative, the applicant is encouraged to present their own tiered approach to care and TA for differentiated and responsive technical assistance:

○ Tier 1: Model (Highest Functioning Facility)

■ Facilities that need some support3 to upgrade to a Comprehensive emergency

Obstetric and Newborn Care (CEmONC)

■ Good management practices and leadership

■ Availability of DHIS data (accuracy and reliability sound)

■ Less than 10% stockout of essential tracer meds

■ Less than 20% vacancy rate

■ Facilities that serve significant populations size (at least 150,000 population or greater)

■ Sound outreach services with good community engagement and client uptake

■ Medium performance in continuum of care along RMNACH and malaria cascade consistently over the last year (cutoff to be determined)

■ Potential to serve as a “center of excellence” to mentor surrounding health facilities

■ Relatively safe and secure for initiating implementation

■ Urban and peri-urban preference for inclusion of referral network facilities

○ Tier 2: Emerging (Medium Functioning Facility)

■ Varied levels of performance in continuum of care along RMNACH and malaria cascade consistently over the last year (cutoff to be determined)

■ Varied management practices and leadership

■ Less than 20% stockout of essential tracer meds

■ Less than 30% vacancy rate

■ Facilities that serve significant populations size (at least 150,000 population or greater)

■ May or may not be lowest performing indicators

■ Varied outreach services with good community engagement and client uptake

■ Likely historical supported USAID facility

■ Relatively safe and secure for initiating implementation

○ Tier 3: Foundational: (Low Performing, but High Population Coverage)

■ Significant Population Coverage (greater than 250,000)

■ Lowest Performing Indicators

■ Significant Financial Investments Required (inputs + TA)

■ Relatively safe and secure for initiating implementation

● Overemphasis on inputs and process and not enough on outcomes: Historical

USAID/Nigeria health system support has been heavily focused on inputs and process driven, with less emphasis on key outcomes (i.e. Health improvement, responsiveness and people-

3 Support can include support recruitment and deployment of specialized healthcare workers, minimal equipment support, minimal rehabilitation to meet “standards” for CeMONC facilities, clear emergency transportation support centeredness). This Activity will target to measure the performance of the Primary Health Care system and networks of care, functions and outcomes.

● Lack of responsive technical assistance: Historical USAID awards did not allow for flexibility for technical assistance making it difficult for USAID support to be responsive to unknown, or new or emerging technical assistance needs.

3. Strategic Alignment

3.1 Alignment to GON Priorities and Reform

Nigeria's 2023–2026 National Health Sector Renewal Investment Initiative (NHSRII) Strategic Vision for the Health Sector aims to save lives, reduce financial hardship, and ensure access to quality healthcare for all Nigerians. To achieve this, USAID is supporting the Government of Nigeria's reform of its approach to primary health care (PHC) and establishing networks of care among PHCs and with secondary care as the primary points for comprehensive emergency obstetric care (CEmONC) and for addressing severe malaria. Ensuring continuum of care back to the community level will also be essential to ensure well-integrated and coordinated people-centered care. This renewed approach will prioritize and expand high-impact and cost-effective investments in communities and serve as a critical entry point to health services in a people-centered health system.

The reform effort requires a comprehensive review of the health sector where proactive health services (acute and chronic) are delivered across the PHC platform. In December 2023, the Coordinating Minister of Health and Social Welfare, Dr. Mohammed Ali Pate, unveiled the NHSRII, garnering support from President Bola Ahmed Adekunle Tinubu, all Nigerian state governors, senior representatives from bilateral and multilateral donors, development banks, and philanthropic foundations. An integrated people-centered approach is also critical as Primary Healthcare Centers are the first level of care in the Nigerian health system, providing an entry point to life-saving HIV, malaria, nutrition, and maternal and childcare services that otherwise would have been lost. Primary Healthcare Centers enable the public sector to expand health coverage and promote equitable access while improving the quality of care through differentiated service delivery models. These models have been effective in reducing mother-to-child transmission of HIV and play an essential role in prevention, preparedness, response, and recovery to public health threats of pandemic potential.

The UPHIP activity will be aligned to the GoN Primary Health Care Strategic Objective: Every Nigerian has equitable access to quality PHC services they need through a system that they trust and contribute to Nigeria Health Sector Renewal Investment Program strategic pillars effective governance, efficient, equitable, and quality health system, and Primary Health Care Development Agency strategic blueprint of an Efficient, Equitable, Quality and Trusted Primary Health Care services.

3.2 Alignment to USAID Priorities

In December 2022, Nigeria was named as one of USAID's Primary Impact Focus Countries, reaffirming the Agency's commitment to accelerate progress in primary health care in close coordination with the President's Malaria Initiative (PMI) and President's Emergency Plan for AIDS Relief (PEPFAR). Primary Healthcare Centers in select states in Nigeria receive comprehensive and integrated support by leveraging existing U.S. government investments and resources and driving more integrated health service delivery and technical assistance.

Primary Impact focuses on harnessing USAID's global health work and accelerating primary health care outcomes by bringing together subject matter experts from Washington D.C., USAID Missions across the globe, and supporting south-to-south learning to expand partnerships with critical stakeholders and multilateral to accelerate progress in health outcomes. These partnerships include USAID contributions to the Global Financing Facility (GFF) to incentivize governments to spend domestic resources on PHC; the Community Health Delivery Partnership (CHDP), a multi-donor structure to promote PHC financing and coordination, specifically for community health workers;

alignment with the priorities of the White House Global Health Workforce Initiative (GHWI) to protect and support frontline health workers; and the strengthening of USAID's localization initiative to support country capacity and community engagement across development sectors.

4. Activity Approach

To address these challenging dynamics and build on USAID’s previous investments and gains made in RMNCH, malaria and global health security services, the proposed activity aims to build a more effective, resilient, and responsive primary healthcare system that can adapt to the changing needs of the Nigerian population.

The development hypothesis of the UPHIP design is:

If USAID/Nigeria advances Quality of Care and improved access4 to primary and secondary health care, then women and children will live longer and healthier lives.

UPHIP activity Theory of Change (TOC)

If Nigerian governments demonstrate political commitment to leverage resources; institute transparent accountable systems; acquire quality and timely supplies of necessary health commodities; hire, retain and deploy health care workers appropriately AND

If Public and private sector health providers are equipped to provide quality services that are responsive to clients’ needs and preferences to drive uptake AND

If Individual and social determinants of health are equitably addressed by government at all levels AND

If The private sector is effectively engaged in the mobilization of resources, health system strengthening and innovative solutions and technology Then mortality and morbidity of newborns, under five-year old children and mothers will reduce.

4.1 Global and Local Models of PHC

Critical components of this award will support the GON's reform efforts to strengthen networks of care, including primary and secondary health care, and reduce maternal and child mortality and morbidity. Five key components of PHC strengthening include: Effective Models of PHC Delivery;

Community Engagement; Subnational and Facility Management; Systems Integration and

4 Access and Quality are intersecting concepts. Access is primarily concerned with the ability to reach and utilize services, whereas quality is about the level of excellence of those services once accessed. Access is frequently addressing geographic access; financial access; cultural access; timely access; and availability access (presence of HCW; medicines; equipment).

Quality addresses issues of safety, effectiveness, patient-centeredness, timeliness (Wait times and delays), efficiency, and equity.

Interoperability; and Resilient Health Systems and Services as shown in Image 1 and explanation of these components below:

Image 1. USAID's 5 Core Components of Primary Impact

Effective Models of PHC Delivery:

● Differentiated Models: A defined primary health care model that includes roles and responsibilities for health care workers and multidisciplinary teams, as well as scopes for systems of care that are contextualized by geography or responsive to local practices.

● Active community outreach: Systems and staff are in place to proactively reach a defined set of populations, which may include health promotion, preventive health services, case finding and treatment.

● Service integration and referral: Functional or physical integration of service delivery across vertical areas into PHC design to ensure continuity, comprehensiveness, coordination, and people– centeredness.

Community Engagement:

● Active engagement of and participation by citizens and civil society organizations in the priority-setting and planning stages of PHC service delivery (the primary focus for this award is how facilities will engage with the community). The future Community Health and Social and Behavior Change award will work with supporting communities to better engage with health facilities.

● Build accountability that relies on civic engagement to directly or indirectly track progress, review community health status, and exact accountability.

Subnational and Facility Management:

● Budget allocation and execution ensure funds are spent as prioritized for PHC and resources are utilized efficiently and with accountability (State-Level Support, BHCPF (Basic Healthcare Provision Fund) oversight, and joint accountability support at State Level Support, in addition to direct financing facility support/business plan development).

● Effective implementation of performance management by trained facility managers that includes supportive supervision, staff motivation, and data used for performance measurement and improvement.

● Information and other data systems must be managed and kept functional and in use to ensure quality data are used for monitoring and evaluation, timely reporting, decision-making, and quality improvement for better patient care.

Systems Integration and Interoperability

● Integrated commodity distribution, storage, and supply/inventory management occur in the supply chain for PHC at the subnational and facility levels.

● Facility and subnational levels execute information systems management and reporting into a single integrated, or at least interoperable, structure that captures data for multiple vertical programs and reporting requirements. This component will be supported through USAID's future investment/award in health information systems strengthening and digital health for improved data use (expected to come online in January 2025).

● Financial Management Information Systems are integrated, increasing digitization, transparency, and accuracy of financial information across the health system.

Resilient Health Systems and Services

● Subnational units and facilities can effectively respond and adapt to public health and other emergencies while sustaining essential primary care services and functions.

● The ability of subnational units and facilities, systems, and services to detect, assess, notify, report, and respond to public health risk.

In 2018, an updated framework was developed from the PHCPI framework—termed '5S-5M-5C' (Image 2 below)—which describes essential service delivery mechanisms for transforming key inputs into functional and equitable PHC. systems. Recognizing the importance of these often-undervalued mechanisms and better understanding how to measure and improve them will be critical for making progress toward the goal of quality Universal Health Coverage for all.

Image 2. 5S-5M-5C

The 5S-5M-5C (Image 2) framework should be tied to USAID's 5 Core Components of Primary Impact (Image 1) to demonstrate the applicant's solution to address all components from systems, inputs, service delivery, and proposed indicators to measure outputs and outcomes over time:

4.2 Improving the Continuum of Care

This activity will enhance the health of women and children in Nigeria by strengthening maternal, newborn, child health, adolescent, reproductive health, malaria, and nutrition service delivery throughout the continuum of care, i.e., from the home to the community to the primary care facility, and the secondary referral hospital. Continuum of care refers to a system that guides and tracks patients through a comprehensive array of age- and stage-based health services spanning all levels and intensities of care. Based on the data below from HMIS and DHIS 2.0. lost to follow-up/dropout from ANC to ANC 4 was 60%. Of those women seeking ANC 4 care, on average, 50% did not deliver at a health facility and of those who did deliver at a health facility, there were varying levels of those whose attendance was attended by a skilled birth attendant. Other opportunities to strengthen improved pregnancy related outcomes based on the data below is also increasing the number of women who seek malaria in pregnancy care (IPTp1 to IPTp3 has, on average, a 53.5% drop out rate), those who sleep under insecticide treated nets (ITNs), and supporting early childhood malaria diagnosis and treatment will be critical as 143,000 children under five years old died from malaria in 2022, as well as preventing pregnancy in the first place for those women/girls seeking to delay pregnancy or space their births.

Looking at postnatal care (PNC) as a critical area to support improved child health practices, including exclusive breastfeeding and immunization, there should be improved compliance with PNC visits and, ultimately, other support to drive more children to be fully immunized by age five and ultimately save lives. When discussing the continuum of care, these critical indicators should be considered and followed by a cohort of women and their children.

See sample Continuum of Care data in Image 4 below.

Image 4. Continuum of Care Data select sites and states (DHIS 2.0)

This Activity aims to build the capacity of urban and peri-urban public and private primary PHCs and referral health facilities (secondary) in planning and delivering client-centered, quality Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) and malaria services. This Activity will improve RMNCAH and malaria status and delivery of client-centered, quality care by increasing readiness of health facilities, increasing healthcare provider and manager competency and performance, strengthening systems for feedback and accountability, and enhancing community participation, thereby increasing client satisfaction and service utilization and ultimately, preventing maternal and child mortality.

The UPHIP activity will also support the testing, implementation, and scaling of proven and promising locally appropriate RMNCAH and malaria innovative models with the great potential to optimize utilization of essential health services, such as the E-MOTIVE trial in the management of Postpartum hemorrhage, safer bundle of care that has the potential to create impact and improve perinatal survival on a national scale, the family planning high-impact practices (HIPs) which are a set of evidence-based family planning practices vetted by experts that are measurable and have demonstrable impact in achieving various family planning outcomes, amongst others. It will also support the implementation and state adaptation of Ending Preventable Maternal Mortality Plan, Every Newborn Action Plan and Child Survival Action Plan.

4.3 The Patient's Perspective

To fully improve coverage, patient-centered care, health-seeking behavior and health outcomes, more intensified support is required to address the demand-side determinants of service use including:

● Financial barriers that limit the ability of patients to pay informal out-of-pocket payments as they may not enroll under BHCPF or Health Insurance or are not able to afford to pay for transportation for visit/institutional birth preference or convenience of accessing care from traditional birth attendants or at religious institutions.

● Cultural or household/family barriers that limit access to care.

● Limited community mapping and identification of potential patients, and, therefore, awareness of who is pregnant in a community.

● Gender barriers, and non-inclusive health programming that limit access to specific segments of the population (inclusive development protects the rights, safety, well-being, and inclusion of underrepresented and marginalized groups).

Technical assistance should include the deployment of proven approaches and strategies to minimize access barriers and ensure equitable primary and secondary healthcare services in focus facilities. These strategies may include:

● Secondment of trained nurses/midwives to engage with traditional (and religious) birth attendants and ensure timely referrals to a health facility;

● Conditional cash transfers;

● Transportation for pregnant women (including establishing an emergency transportation system) to reduce delays in seeking healthcare for women experiencing danger signs in pregnancy and delivery, and for sick newborns and infants;

● Ensuring voluntary and informed choice for family planning.

The Activity is expected to help ensure that pregnant women and their families are informed and enabled to take timely and appropriate action when danger signs occur.

Furthermore, the Activity will leverage efforts led by the future USAID community health and social and behavior change award in addressing the delay in women and children's decision to seek care (First Delay) and the delay in identifying the health facility (Second Delay). The activity seeks to strengthen the feedback mechanism on the client-service provider's experience of care; a well-functioning patient feedback system can contribute to improved quality of healthcare and systems accountability. Multiple patient feedback systems operate in Nigeria in the context of political commitment to accountability and patient responsiveness to the uptake of primary health care services; the latter is constrained by limited patient awareness of feedback channels, lack of guidelines and documentation of these processes, local political dynamics and accountability. It is critical to ensure people's rights within a non-threatening environment where people can express their views; a strengthened system will enable health workers to value, document, analyze patient feedback, and communicate timely actions that will improve their satisfaction and trust in their health systems. This is a strategic vision for the current political leadership in Nigeria, and the government has committed to improving patient satisfaction rates with PHC services under the Health sector renewal program.

5. General Activity Parameters

5.1 Target Beneficiaries

Given that the entry point for UPHIP is focused on RMNCH and malaria, the direct beneficiaries must be women, adolescents and children under-five. Indirect beneficiaries may include the millions of Nigerians who utilize public and private health services, healthcare workers and managers, the MOH and local government. The general population will benefit as a result of the improved capacity of facilities to deliver quality services. MOH and local government will benefit from the capacity building received, ultimately contributing to the overall sustainability of the Activity. Specific interventions under UPHIP will identify other priority populations and hard to reach communities. It is expected that UPHIP will, ultimately, result in improved health services for the catchment population of facilities that are supported under this activity.

5.2 Geographic Coverage

As the country is moving to a sector wide approach, and multiple surveys including the National Demographic and Health Survey 2023/2024 are underway, states have not been selected for intervention. State and other geographic selection will be done in a later phase of this NOFO in partnership with USAID, the Federal Ministry of Health, the National Primary Healthcare Development Agency, other development partners and other stakeholders, after the release of important data sets to inform USAID’s geographic prioritization.

The 2018 National Demographic and Health Survey (NDHS) confirmed widespread disparities in health outcomes across Nigeria and at all levels of healthcare provision. In response to these disparities the geographic coverage of UPHIP must be divided geographically into national/central interventions and State/LGA/facility level interventions. National/central interventions may include, but are not limited to, interventions such as participation in TWGs, policy development and other interventions which respond to national MCH, FP and malaria priorities. State/LGA interventions may include, but are not limited to, targeted interventions such as technical assistance and support to State or LGA Health Management or Quality Improvement Teams, communities, facilities (secondary referral hospitals, Primary Health Care Centers, and Health Posts) and providers. Geographic coverage for the State/LGA category of interventions must be targeted and these will be determined during the development of the implementation plan. Finally, USAID envisions that the suite of interventions offered under UPHIP may differ according to geographic location, for example a particular LGA/facility may require more assistance in FP than MCH.

The geographical coverage of this Activity may change to respond to GON requests, and/or the United States Government’s current and future plans and priorities. Applicants are encouraged to identify activities at the national level as well as designing scenarios for state/LGA level engagement based on the applicant’s knowledge. While some activities may be universal regardless of the chosen geography, the applicant may choose to highlight proposed activities that would be most relevant for different States/LGAs.

6. Collaboration

6.1 Complementary USAID Support

Essential and safe 24-hour RMNCAH services rely on reliable electricity and potable water to uphold infection, prevention and control (IPC) practices. After the Activity is awarded, partners are expected to provide data-driven assessment and propose prioritized facilities for solarization and WASH integration. Similarly, the successful applicant(s) will work with the government and or other sources of financing. USAID has numerous activities that focus directly on health including RMNCH, malaria, HIV, tuberculosis, and global health security services which may also be able to provide lessons learned to inform the approach. The Government of Nigeria Health Sector Strategic Blueprint (HSSB) framework provides an opportunity to synergize all USAID/Nigeria health program support both at the national and sub-national level through the implementation of the action plan and joint annual reviews.

6.2 Coordination with Government Entities and structures

This activity is expected to work closely with the MOH, State Primary Health Care Development Agency (SPHCDA) and Local Government Health Authorities (LGHAs), to build capacity and enable government systems and processes for strengthening the quality of respectful, gender-responsive integrated RMNCH and malaria services. This activity will avoid creation of new implementation and reporting structures and instead work within the existing public sector health service, and with existing systems. The applicant is expected to interact with government entities at all levels from health facility to national level through for example technical meetings and any opportunities which arise to enhance coordination.

The Government of Nigeria is currently revising the Basic Healthcare Provision Fund guidelines to accelerate reduction in maternal and child mortality and other health related issues and double the number of facilities that are funded. Therefore, the successful applicant(s) may be required to support new reform efforts at BHCPF PHC facilities to ensure smooth implementation and better care and coverage of targeted populations. This may include but not limited to:

● improvement in the “quality of spending” by supporting business plan development of direct financial facility funds (and planning and tracking utilization for procurement of medicine, hiring of healthcare workers, other required support),

● support to newly deployed health fellows (responsible for financial management and other responsibilities),

● introduction and support to potential…