Notice of Funding Opportunity No. 72062025RFA00003 USAID Community Health.pdf

ISSUE DATE: December 11, 2024

DEADLINE FOR QUESTIONS: January 8, 2025, 4:30 PM WAT

CLOSING DATE AND TIME: January 24, 2025, 4:30 PM WAT

PROGRAM TITLE: USAID Community Health Activity

SUBJECT: Notice of Funding Opportunity Number (NOFO):

72062025RFA00003

Dear Interested Parties, The United States Government, as represented by the U.S. Agency for International Development

(USAID)/Nigeria seeks applications from qualified entities to implement the USAID Community

Health Activity. Eligibility for this award is restricted to local Nigerian organizations.

USAID intends to issue one or more awards to the applicant(s) who best meet the objectives of this funding opportunity based on the merit review criteria described in this NOFO. Eligible parties interested in applying for the USAID Community Health Activity are encouraged to thoroughly read this NOFO.

To be eligible for award, the applicant must provide all information as required in this NOFO and meet eligibility standards in Section B of this NOFO. This funding opportunity is posted on www.grants.gov and may be amended. It is the responsibility of the applicant to regularly check the website to ensure they have the latest information pertaining to this NOFO and to ensure that it has been downloaded from the internet in its entirety. USAID bears no responsibility for data errors resulting from transmission or conversion process.

USAID/Nigeria encourages all interested organizations to register in the USAID Partner Directory

(https://www.workwithusaid.gov/partner-directory). The USAID Partner Directory is a listing of development organizations working to make sustainable changes in their communities and around the world. Showcasing your organization increases your visibility among USAID

Headquarters, Missions, and current partners looking for collaboration opportunities. It also provides a space for applicants to search for other organizations that may complement their expertise to form a strong technical approach in response to this solicitation.

http://www.grants.gov https://www.workwithusaid.gov/partner-directory

USAID/Nigeria Notice of Funding Opportunity No. 72062025RFA00003 USAID Community Health Activity

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 this NOFO posted to www.grants.gov.

Issuance of this NOFO does not constitute an award commitment on the part of the Government nor does it commit the Government to pay for any costs incurred in preparation or submission of comments/suggestions or an application. Applications are submitted at the risk of the applicant.

All preparation and submission costs are at the applicant’s expense.

Thank you for your interest in USAID programs.

Sincerely, Marva Butler

Agreement Officer mailto:abujasolicitations@usaid.gov

TABLE OF CONTENTS

SECTION A: FEDERAL AWARD INFORMATION 4

SECTION B: ELIGIBILITY 7

SECTION C: PROGRAM DESCRIPTION 9

SECTION D: APPLICATION CONTENT AND FORMAT 36

SECTION E: APPLICATION REVIEW INFORMATION 47

SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION 51

SECTION G: FEDERAL AWARDING AGENCY CONTACT(S) 57

SECTION H: OTHER INFORMATION 58

ANNEX A - ABBREVIATIONS AND ACRONYMS 59

ANNEX B - STANDARD PROVISIONS 62

SECTION A: FEDERAL AWARD INFORMATION

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

USAID intends to award one or more Cooperative Agreements pursuant to this Notice of Funding

Opportunity (NOFO).

USAID intends to provide up to $35,000,000 for the USAID Community Health Activity. Actual funding amounts are subject to the availability of funds. USAID reserves the right to fund any or none of the applications submitted.

A.2 Start Date and Period of Performance for Federal Awards

The anticipated period of performance is five (5) years, with an estimated start date upon the

Agreement Officer’s signature.

A.3 Substantial Involvement

As per ADS 303.3.11, USAID/Nigeria will remain substantially involved during award implementation. The substantial involvement envisaged under the resulting awards will include the following:

a) The Agency’s approval of the recipient’s implementation plans during performance.

USAID generally only requires approval of implementation plans annually; however, where changed contexts or new information require a pivot in the activity, USAID may consider changes to an implementation plan. These plans include:

1. Annual Work Plans

2. 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) Agency 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) Direct agency operational involvement or participation to ensure compliance with statutory requirements such as civil rights, environmental protection, and provisions for the handicapped that exceeds the Agency’s role that is normally part of the general statutory requirements understood in advance of the award.

h) 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.

A.4 Authorized Geographic Code

The geographic code for the procurement of commodities and services under this program is

Code 937, this 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.

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.

A.5 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 Community

Health activity 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

B.1 Eligible Applicants

Eligibility for this NOFO is restricted to local 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; and

2. Has as its principal place of business or operations in; and

3. Is

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

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

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.

To be eligible for award of a Cooperative Agreement, in addition to other conditions of this

NOFO, organizations must have a politically neutral humanitarian mandate, a commitment to non-discrimination with respect to beneficiaries and adherence to equal opportunity employment practices. Non-discrimination includes equal treatment without regard to race, religion, ethnicity, gender, and political affiliation. Applications will not be accepted from individuals.

B.2 Cost Sharing

Cost Sharing is not required for this activity.

B.3 Other

An organization may submit only one (1) application as the prime applicant under this notice of funding opportunity. However, organizations participating as a member of a consortium may elect to participate as a sub-awardee in another consortium under a different application.

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.

A 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.

[END OF SECTION B]

SECTION C: PROGRAM DESCRIPTION

This funding opportunity is authorized under the Foreign Assistance Act (FAA) of 1961, as amended. The resulting award will be subject to 2 CFR 200 – Uniform Administrative

Requirements, Cost Principles, and Audit Requirements for Federal Awards, and USAID’s supplement, 2 CFR 700, as well as the additional requirements found in Section F.

C.1 Introduction

The USAID Community Health activity, hereafter referred to as “the Activity”, will support priority populations and communities, community organizations and networks, and public- or private-sector actors that work in partnership with civil society at the community level, in the design, delivery, monitoring and evaluation of activities aimed at achieving the purpose of increasing the adoption and sustained uptake of priority health behaviors, services, and products.

The Activity will achieve its purpose through the following results:

IR 1: Adoption and sustained practice of healthy behaviors improved

IR 2: Nigeria’s community-based health worker program operationalized to improve equitable access to quality community-based health services, Social Behavior

Change (SBC) and risk communication and community engagement (RCCE) interventions.

IR 3: Community-led systems for health governance and accountability strengthened.

CCR: Leadership, visibility and voice of underrepresented and affected groups, including women in delivery and accountability of health services enhanced.

C.2 Background and Problem Analysis

Nigeria accounts for 2.4 percent of the world’s population but is responsible for 10 percent of global maternal deaths with a Maternal mortality ratio (MMR) of 512/100,000 live births1. Many of these deaths occur outside of a health facility, as nearly 6 in 10 births (61 percent) happen at home (NDHS 2018). Each year, approximately 262,000 babies die at birth, the world’s second highest national total. More than half of the under-five deaths – 64 percent – result from malaria, pneumonia or diarrhea (UNICEF, Situation of women and children in Nigeria). This dismal performance in RMNCAH+NM indices is attributed to gross limitations of both the supply and demand factors in the causal pathways for these deaths and worsened by the high burden of

1https://www.unicef.org/nigeria/situation-women-and-children-nigeria#:~:text=Nigeria's%2040%20million%20women%20of,global%20deaths%2 0for%20pregnant%20mothers.

communicable and non-communicable diseases. Additionally, even though Nigeria has recorded unprecedented increases in tuberculosis treatment coverage in the last five years moving from

24% to 74%, gaps still exist among key populations, such as children and men who make up 10% and 54% of those notified, respectively.

On the supply side, a shortage of healthcare workers in Nigeria limits coverage of health services for Nigeria’s population. This is particularly felt by communities who face long travel and poor access to formal health facilities. A strong community-level health system can increase access to care and can improve health outcomes. However, many national attempts to improve the community component of primary health care (PHC) have not achieved their intended goals. In

2018, the implementation of the Community Health Influencers Promoters and Service (CHIPS) program commenced with a goal to integrate and harmonize all community-based health worker programs into one category for improved and equitable delivery of basic PHC services, increasing coverage and contributing to the reduction of maternal and child morbidity and mortality. As of

February 2024, an assessment by the National Primary Health Care Development Agency

(NPHCDA) documented that poor political commitment and ownership at the subnational level, grossly inadequate funding, capacity gaps and poor motivation of the CHIPS personnel, gaps in the supply chain for commodities and inadequate supportive supervision systems contributed to the uneven progress with the implementation of the CHIPs program across states. Accordingly, and in line with the National Health Sector Renewal Investment, the NPHCDA led the redesign of the community-based health workers (CBHW) program, addressing gaps and building on gains of the CHIPS program. This Activity will support the operationalization of the GoN’s redesigned

CBHW program, as the primary human resource vehicle for increasing access to health services, improving uptake of behaviors and community-based disease surveillance.

See Attachment 1: for detailed country and health context (part A), description of development challenges (part B), key USAID and GoN health strategies (part C) and summary of USAID’s historical investments in community health, SBC and RCCE (part D).

C.3 Activity Description

The purpose of this Activity is to increase the adoption and sustained uptake of priority2 health behaviors, services, and products. This Activity will achieve these through three core areas of work:

First, this activity will lead the design and implementation of theory-informed, evidence-based, locally-led SBC and risk communication and community engagement (RCCE) programming. SBC

2 Data-informed consultative and iterative process, involving this Activity, other USAID-funded Activities, USAID, GoN, and other stakeholders, to prioritize and select a range of clearly defined behaviors, which will ideally vary for different states or geographical regions or sub-populations.

https://docs.google.com/document/d/1rOegAHVtRdeM1TRpvPyuLamWTYpMak9EekPNczmYQkI/edit?usp=drive_link programming is intended to foster positive health practices in households and communities and support changes in social, gender and cultural norms that will reinforce and maintain these practices. SBC is defined as the coordinated use of a range of communication and noncommunication approaches - including mass media, community-level activities, nudging and interpersonal communication - to change individual and family behaviors, and improve social and gender norms in support of improved health outcomes. High-quality SBC is evidence- and theory-driven and identifies and addresses specific drivers of health beliefs and behaviors at individual, interpersonal and collective levels. It follows a proven model for planning, creative development, implementation, and evaluation, and emphasizes ongoing engagement and participation of the primary audience and other stakeholders.

Accessibility and convenience factors are known barriers to translating behavioral intention to action hence the second core area of work that this activity will advance to achieve the stated result and purpose is to facilitate the operationalization and scale-up of community health workers to expand access to essential community-based health services, and drive demand for facility-based health services. These efforts will be guided by the program guide for CBHWs, the package of interventions, and other relevant national policies listed in Attachment 1 part C.

Under this component, this Activity will: i) bridge the gaps in access to health information, products, and services through direct implementation of the community component of PHC, critical to attaining Universal Health Coverage (UHC); ii) improve the community-PHC continuum of care by linking individuals and households to the primary health facilities (public and private) and higher-level care (where needed) and iii) support behavior maintenance and enhance follow-up through interventions that support individuals and households to stay connected to the primary health systems that deliver services.

Led by the NPHCDA, the Nigerian government has proposed recommendations for the redesign of the country’s CBHW model. The major thrust is the proposition of a two-cadre model (see figure 1 below), including skilled and formally trained Junior Community Health Extension

Workers (JCHEWs) and less skilled but trained auxiliary/lay health workers. Both tiers of CBHWs will work collaboratively to deliver a broad set of services, products and SBC interventions in communities. Applicants will support operationalization of the redesigned CBHW program in select geographic areas to be determined with GoN and USAID/Nigeria. Efforts may include state context specific adaptation of the program, including support for mapping, recruitment

(including transition of current community health workers/volunteers to government payroll), training and deployment of community health workers.

Given the fluidity of the national roll-out of CBHW redesign, successful applicants may be asked to pay for the salaries for CBHWs in the short-term, within government approved rates, which https://docs.google.com/document/d/1snRFllexRvkOOXQiQoMQ4BTHfDxQPNd3/edit#heading=h.gjdgxs https://docs.google.com/document/d/1W5UR7YQBeemd54YU_Nj6kgfSPrQx-AaT/edit https://docs.google.com/document/d/1rOegAHVtRdeM1TRpvPyuLamWTYpMak9EekPNczmYQkI/edit?tab=t.0 https://docs.google.com/presentation/d/1NpiOFBSab4N9MsSCJwIqXFqsR1PZpttZ/edit#slide=id.p1 may vary by state, while developing transition models with GoN leadership. Based on the estimated costing of the national CBHW guide, an average cost of $1,580 is required for kitting, salaries and incentives per CBHW on an annual basis. This estimated average cost does not include training, supervision, or other recurring costs. Support for strengthened supportive supervision, data collection, routine on the job training and mentoring are other areas that the applicant can be expected to support. Technical assistance to support institutionalization of the community health workers may include supporting the evidence base to guide adaptive management/scale of the CBHW program and or policy development. With support from

USAID/Nigeria, it is expected that the applicant will work in partnership with other development partners, GoN and other implementing partners to support coordination of the national CBHW roll-out/monitoring.

Figure 1: Proposed two-cadre CHW. Culled from the NPHCDA CBHW Guide

The third core area of work that this Activity will advance is the strengthening of social accountability and governance for health at the local government and ward levels. This result will improve community knowledge and understanding of health and will engage individuals, households, and communities to make informed decisions in managing their own health.

Building the capacity of civil society organizations (CSOs), such as community-based organizations (CBOs) and faith-based organizations (FBO), other community platforms, etc. will be critical to advocate for more transparent and responsive health services (e.g., serving as a bridge between clients and health service providers). With explicit focus at community level, engagement of local CSOs will improve health system functionality, increase community health behaviors and care-seeking practices and ensure high-quality, client-centered health services at all levels. Through these results, it is expected that the apparently successful applicant will: 1)

Improve community engagement, ownership, and ability to make informed decisions about its own health; 2) Enhance CSO capacity to advocate for improved health system accountability, transparency, and responsiveness and 3) Strengthen accountability systems and platforms to improve the health outcomes.

With recent government reforms to achieve full autonomy for, and directly fund local government areas (LGAs), efforts would include those that empower LGA health teams, ward and community health governance structures such as Ward and Village/Community

Development Committees (WDCs and V/CDCs) to take responsibility to improve their communities’ health through enhanced ownership and accountability systems and platforms for health. This Activity will also engage and strengthen the capacity of existing coalitions of health

(and non-health) CSOs, FBOs and CBOs and other health allies such as the media to foster greater community engagement and informed participation in PHC service planning, delivery and monitoring through existing platforms such as facility management committees or new innovative platforms. Community feedback mechanisms, including community score cards, citizen voice surveys, etc. could be considered.

C.4 Result Framework and Expected Results

Figure 2 below depicts the Results Framework for the Community Health and Behavior Change activity.

Applicants will propose interventions that will achieve the expected results (as measured by indicators and targets) for each sub-IR and will provide the rationale in the activity monitoring, evaluation and learning plan (MELP).

IR 1: Adoption and sustained practice of healthy behaviors improved.

Health promoting behaviors and healthy lifestyle patterns are a fundamental concept and determinant of general health status. Evidence supports that when uptake of the accelerator behaviors (outlined in Table 1) is high, they have the potential to greatly reduce maternal and child deaths, prevent the occurrence and progression to chronic diseases. To adopt health behaviors, individuals should understand the benefits of practicing them, and have both the intention and ability to practice them and consequently seek health services. The applicant’s approach should be informed by addressing the various factors that prevent the adoption or sustainment of positive individual and household health behaviors. Applicants are expected to define strategies based on data and evidence, test and then scale3 behavior change approaches.

Table 1 below summarizes current uptake of key health behaviors, not exhaustive list, within the purview of this activity. Applicants should be prepared to provide innovative solutions that will help accelerate uptake of these behaviors among priority populations, in targeted states.

TABLE 1

Behavior

Uptake (NDHS 2023-24)

Pregnant women attend a complete course of antenatal care

(MH)

52 percent

Pregnant women deliver with the assistance of a skilled provider

(MH)

46 percent

New mothers’ complete postnatal appointments with a skilled provider (MH)

43 percent

Pregnant women take at least three or more doses of intermittent preventive treatment of malaria (IPTp) during ANC visits (Malaria/MH)

26 percent

Mothers initiate breastfeeding within one hour after delivery (NH/Nutrition)

36 percent

3 Defined as reaching the proportion of primary and secondary audiences required to achieve and sustain population-level behavior change within target populations.

Caregivers provide essential newborn care immediately after birth (NH)

42 percent i.e. PNC for babies within 2 days

Mothers breastfeed exclusively for six months after birth (NH/Nutrition)

29 percent

Caregivers seek full course of timely vaccinations for infants and children under 2 years (N/CH)

39 percent

Caregivers seek prompt and appropriate care for fever (Malaria/CH)

60 percent4

Caregivers provide appropriate treatment for children with diarrhea, as well as symptoms of acute respiratory infections (ARI) at onset of symptoms (CH)

60 percent

Infants 6-24 months fed with adequate amounts of nutritious, age-appropriate foods to children from 6 to 24 months of age, while continuing to breastfeed (CH/Nutrition).

12 percent

After a live birth, women or their partners use a modern contraceptive method, including Long Acting Reversible Contraceptives, to avoid pregnancy for at least 24 months

(FP/RH)

15 percent

Individuals sleep under an insecticide-treated net (ITN) (Malaria) 60/66 percent

(CU5/PW5)

Caregivers demand test before treatment (Malaria) 20 percent6

Tuberculosis

Correct beliefs and knowledge about TB stigma (women, men) 26 and 23 percent

Knowledge of common symptoms of TB (women, men) 64 and 70 percent

This activity will maintain a focus on Preventing Child and Maternal Death accelerator behaviors as outlined in the table above. Other priority behaviors include:

6 Percentage of children under age 5 with a fever in the 2 weeks before the survey who had blood taken from a finger or heel for testing. This is a proxy measure of diagnostic testing for malaria

5 Children Under 5/Pregnant Women

4 This is percent of caregivers who sought care for sick children and not those who sought prompt care i.e. care within 48 hours of onset of symptoms

● Individuals seek prompt and appropriate care for signs and symptoms of TB (persistent cough lasting more than two weeks) (TB)

● Individuals seek timely testing and adhere to TB treatment, as prescribed (TB)

● Community members treat individuals affected by TB with the same dignity as anyone else (TB)

● Caregivers wash hands with soap under running water at four (4) critical times [after defecation, after changing diapers, before food preparation and before eating]

(GHS/Cross-cutting)

Upon determination of states post award, Applicants will propose data-informed, geographically differentiated mix of priority behaviors and a package of SBC interventions to improve uptake, among priority populations, in targeted states. Sound understanding of local context, local and global best practices/solutions, innovations, and measurement and demonstration of results are expected. When results are not changing, adaptive management principles should be deployed to refine solutions. Accelerating and sustaining the achievements of SBC programming hinges on three critical factors: 1) consistent application of theory and data by local partners; 2) strong monitoring and evaluation (M&E) of behavioral determinants and outcomes to continue learning and building evidence for effective SBC interventions and 3) local leadership, policy support, and financial investments. USAID seeks creative and technically sound leadership from Applicants in proposing the best solutions to these critical factors.

Approaches should demonstrate alignment with USAID’s localization vision to “place local communities in the lead to either co-design a project, set priorities, drive implementation, or evaluate the impact of programs.” This Activity will incorporate elements from USAID’s locally-led programs indicator which lays out four categories of good practices in local leadership. Activities under this IR will emphasize rapid, robust, and programmatically useful formative research, concept- and pre-testing, and monitoring.

Given the multiple outbreaks of public health interest in Nigeria, this Activity will support the systematic detection and reporting of events that are led by community members. The role of communities in preventing, detecting and responding to local health threats is critical in improving the lives of Nigerians. One of the principal advantages of community-based surveillance is that it ensures effective communication of unusual events or changes in the health status of residents in a community to authorities and, importantly, gives a voice to communities, enabling early detection and response to potential epidemics, making it possible to stop them before they start.

The three sub-intermediate results under IR 1 are:

https://www.usaid.gov/sites/default/files/2022-12/USAIDs_Localization_Vision-508.pdf https://www.usaid.gov/sites/default/files/2023-07/Public%20Copy%20of%20Locally%20Led%20Programs%20PIRS_1.pdf https://www.usaid.gov/sites/default/files/2023-07/Public%20Copy%20of%20Locally%20Led%20Programs%20PIRS_1.pdf

SIR 1.1: Contextually relevant SBC and RCCE programs designed, implemented and adaptively managed

SIR 1.2: Multi-hazard risk communication in health emergencies strengthened

SIR 1.3: Performance-related attitudes, norms and behaviors among health care providers and system actors improved

SIR 1.1: Contextually relevant SBC and RCCE programs designed, implemented and adaptively managed.

Recent behavioral sentinel surveys as well as evaluations of USAID-funded SBC interventions have increased the understanding of programmatic determinants of success. These determinants include but are not limited to i) the use of formative research; ii) grounding approaches and interventions in behavioral theory; iii) audience or population segmentation and behavioral objectives; iv) continued engagement of stakeholders in design, implementation, and monitoring; and v) use of multiple channels and strategies to influence key determinants of behaviors. Careful considerations of these determinants in the design of SBC programs are important to improve uptake of live-saving behaviors and services at the community level to ultimately drive down maternal and child morbidity and mortality. This Activity will pay close attention to the existing evidence on the effectiveness of various intervention types to influence uptake of behaviors and how this effectiveness varies across behaviors in proposing appropriate levels of effort across intervention types, behaviors and subpopulations. This activity will also contribute to measurable shifts in the underlying social norms7 and beliefs that constrain the practice of priority health behaviors. Other critical considerations for this activity will be the promotion of newer tools and/or behaviors e.g. uptake of recommended doses of the malaria vaccine. Approaches will also carefully examine the evidence on approaches to SBC integration and should clearly demonstrate opportunities for both heightened impact and economies of scale in programming.

Widespread access to mobile phones, social media and digital technology has transformed the communication landscape in Nigeria, enhancing interpersonal connectivity, and accelerating the spread of new ideas and norms as well as misinformation/disinformation. This Activity will consider recommendations in the USAID digital divide learning brief as well as those from other existing literature to increase gender equitable access to, and use of digital tools for SBC programming. Finally, this Activity will employ co-creation8 approaches that elevates diverse local voices, including of people living with disabilities, across the program cycle and facilitate joint

8 Defined by USAID as an intentional design approach to address a specific problem, challenge, question, or to gain further insight on a topic of interest through a participatory process whereby participants share power and decision-making.

7 May include improving women’s decision-making power; addressing cultural taboos around sex and sexuality; reducing social tolerance for forms of gender-based violence or addressing TB-related stigma and its impact on uptake of behaviors along the continuum of care; testing to treatment adherence https://drive.google.com/file/d/1zBJeCZvthGMewgozWBi6peP-ekPLay1m/view?usp=drive_link https://pdf.usaid.gov/pdf_docs/PA00XR5P.pdf https://drive.google.com/file/d/12vGzJdCUB5CDyrNPTysNT0qrAPIxhI4W/view?usp=sharing ownership of USAID’s investment while addressing ways in which gender and power inequalities can limit certain people’s access to, equitable participation in, and benefit from SBC interventions.

SIR 1.2: Multi-hazard risk communication in health emergencies strengthened.

In addition to proactively mainstreaming risk communication interventions, as maybe needed, into routine SBC programming implemented (IR 1.1), this Activity will provide agile9 risk communication design and implementation support as part of response to outbreaks or emerging pandemic threats. This

Activity, working closely with affected populations and communities, governments, and other partners, will design and implement interventions focusing on pre- and post-event strategic preparedness and response. The Activity will i) demonstrate the value of investing in “preparedness and readiness” and “response” loops through shifts from reactive to proactive RCCE programming ii) facilitate coordinated engagement of communities prior to, throughout the duration of and recovery from an event or emergency; and iii) foster community ownership by leveraging systems and structures. This

Activity will use data to guide the design of interventions for any of Nigeria’s prioritized zoonotic diseases10 and other known threats (cholera, meningitis etc.). This Activity will leverage climate and disease data for the pre-positioning of messages to break transmission chains for recurrent zoonotic diseases like Lassa fever and waterborne outbreaks like cholera.

This Activity will continue to support GoN to strengthen the application of the One Health approach for readiness for outbreak response (with an increased focus on animal and environmental health sectors) and collaborate with local partners for proactive community engagement to promote the practice of preventive behaviors that encourage healthy living for humans and animals in their shared environment. Additionally, this activity will provide RCCE support for priority vaccines & reactive vaccinations during outbreaks; provide technical support for the development of RCCE strategies, policies, and guidelines, that address gaps and provide a framework for health security; increase investments in subnational capacity strengthening for

RCCE and strengthen partner coordination and collaboration within the RCCE and One Health ecosystem.

10 Lassa fever, yellow fever, rabies, mpox, highly pathogenic avian influenza and bovine TB

9 Agility here refers to the ability to mobilize expertise (or man) and material resources in support of rapid response teams to affected states and communities.

SIR 1.3: Performance related attitudes, norms and behaviors among health care providers and system actors improved.

Health system actors, especially health care providers, are both a priority audience for behavior change efforts and key change agents for affecting clients’ behaviors. Strengthening the health system to support health care providers and other health systems actors more effectively improves the enabling environment for behavior change in individuals, communities, and institutions. Poor communication and counseling can erode community trust in the health system. This Activity will leverage growing evidence on strategies, tools, and approaches for strengthening "service communication" by improving linkages between SBC and service delivery partners and carefully consider ways to effectively integrate SBC at three stages of the service delivery process - see figure 3. This Activity will advance health systems' or ecosystems approach to changing behaviors of health providers through attention to the complex set of factors that are both internal and external, how these factors interact with each other and how they influence provider behavior, and within service delivery contexts such as facility or community-based. Interventions under this IR will be directed at facility-based health workers as well as CBHWs. This Activity will drive broader application of successful solutions across health areas, work closely with USAID service delivery activities (PHC Improvement Program and TB

Service Delivery) to improve provider attitude and client management skills. This Activity will enhance engagement with relevant providers to create shared norms and peer-led approaches, explore client’s expectations on the quality of care; clients experience of care and elements of respectful care.

IR 2: Nigeria’s Community-Based Health worker (CBHW) Program operationalized to improve equitable access11 to quality community-based health services, SBC and RCCE interventions.

As part of broader efforts to achieve UHC, there is recognition and evidence, globally and in

Nigeria12 that Community-based Health Resource Persons (CHRPs)13 can effectively deliver a range of preventive, promotional and curative primary health services and thus, contribute to reducing inequities in access to healthcare information and products. In Nigeria the CBHW program is working to professionalize, sustain, and integrate CHWs within the health workforce and health systems. The Activity will harness the potential of a cadre, loosely referred to, for the purpose of this solicitation, as CHRPs to enhance the delivery of fit-for-purpose primary health including TB services, SBC interventions and products at community level to increase equitable

13 For this Activity, CHRPs refer to a range of public and private sector actors including but not limited to community health volunteers; Junior Community Health Extension Workers (JCHEWS); Community Health Influencers and Promoters (CHIPS); Volunteer Community Mobilizers (VCMs); home-based care volunteers; health educators; health promoters; Community Based Organizations (CBOs) that provide health services;

Proprietary and Patent Medicine Vendors (PPMVs); community pharmacists; community informants; community orientation and mobilization officers (COMOs) and Traditional or Mission Birth Attendants (TBAs/MBAs).

12 Nigeria’s task shifting and task sharing policy for essential health care services.

11 Affording every individual a fair opportunity to attain their highest level of health regardless of social or demographic factors, with particular emphasis on underserved, socially excluded, and vulnerable populations (USAID HSS Vision 2030) https://www.ghspjournal.org/content/11/Supplement_1/e2300314 https://breakthroughactionandresearch.org/technical-areas/provider-behavior-change/ https://breakthroughactionandresearch.org/provider-behavior-ecosystem-map/ https://www.baproviderbehaviorecosystem.org/ https://breakthroughactionandresearch.org/wp-content/uploads/2020/10/Blueprint-Applying-Behavioral-Insights-Malaria-Service-Delivery.pdf https://advancefamilyplanning.org/sites/default/files/resources/Nigeria%20taskshifting%20policy-Aug2014%20REVISEDCLEAN%20_Approved%20October%202014.pdf coverage, reduce maternal and child illnesses and deaths and contribute to lower disease burdens.

This Activity will provide support ranging from community mobilization, selection of CHRPs, cascade training, mapping, house numbering and assignment of workload, kitting, and tooling.

Interventions will intentionally focus on equity through approaches such as the use of population14 and health coverage15 data to identify and deploy community-based services to

“hard-to-reach”, underserved and unserved populations, including but not limited to people with disabilities (PWDs), unmarried adolescents and youth etc. This Activity will support the operationalization of the revised CBHW program to enhance access to a range of quality community-based health services. This Activity will support efforts at the subnational level, to develop or adapt existing implementation guidelines to the context of states. This will entail efforts to increase the participation of relevant community structures and representatives in state-led planning of set priorities, and selection of CHRPs, using predefined government criteria as well as those that support the co-development of modalities for performance monitoring and problem solving.

The scope of preventive, promotive and curative services provided by CHRPs will be guided by the national CBHW guide, the FMOH strategic blueprint for the community service component of the NSHRII, as well as other relevant policies. Select services will include but not limited to a range of testing services e.g. rapid diagnostic tests for malaria and screening services e.g.

presumptive TB case identification and referral, Middle Upper Arm Circumference screening in children under 5 for moderate to severe malnutrition, self-care diagnostics, etc.; provision of non-prescriptive services e.g. short term FP methods, treatment of uncomplicated malaria and diarrhea etc.; disease surveillance and reporting as well as referral management and linkages to formal public and private sector service delivery platforms (including facility-led community outreaches) – detailed here.

Applicants will propose models to clearly focus on community-level delivery of the defined package of interventions such as home visits or community dialogues and draw applicable lessons from successful and promising approaches for the integrated community case management of illnesses in children in Nigeria. Applicants will also clearly demonstrate linkages between proposed models and those led by facility-level actors such as PHC-led outreaches to communities, mobile clinics etc.

The four sub-intermediate results under IR 2 are:

15 Proportion of eligible population or catchment reached with defined/core set of health services.

14 Population coverage refers to "catchment" or share of population eligible for a core set of health services.

https://docs.google.com/presentation/d/1NbVMnn-t0l648cxVpI3jQRodk591dw_Q/edit#slide=id.p10 https://docs.google.com/presentation/d/1YtBEbKWhggBBPjCJrh1xRAIBh7UDkxfO/edit#slide=id.p1 https://cdn.who.int/media/docs/default-source/mca-documents/child/who-unicef-joint-statement-child-services-access.pdf https://cdn.who.int/media/docs/default-source/mca-documents/child/who-unicef-joint-statement-child-services-access.pdf

SIR 2.1: Capacity16 for delivery of quality community-based health services, SBC interventions and disease surveillance improved.

SIR 2.2: Provision of culturally acceptable and gender-sensitive community-based health services improved.

SIR 2.3: Community-based surveillance (CBS) and reporting of infectious diseases strengthened.

SIR 2.4: Bi-directional community-facility referral systems strengthened.

SIR 2.1: Identification, training and deployment of community-based health workers in select geographies supported.

Successful community-based health worker programs require building local capacity17 by meaningfully engaging local communities to define needs, selection of, and ongoing support to

CHRPs. This Activity will support efforts at the subnational level, to develop or adapt existing implementation guidelines, increasing the participation of relevant community structures and representatives in state-led planning of set priorities, and selection of CHRPs, using predefined government criteria as well as those that support the co-development of modalities for performance monitoring and problem solving. This Activity may leverage existing resources such as the national CBHWs training manual (currently being revised), to support the development of training plans, deployment of cascade trainings to enable the acquisition of competencies necessary for the delivery of expected preventive, promotive, diagnostic, and curative primary health services, identification of danger signs as well as quality two-way referrals.

Training will incorporate community components of the integrated disease surveillance and reporting module to increase capacity for the identification or detection and reporting of suspected cases for priority zoonotic diseases (PZDs); improve capacity for the use of service and commodity data and referral management tools; improve capacity for personal, infection prevention and control and build skills to support the unique health needs of PWDs. Where epidemiological needs require it, CHRPs will be trained to deliver disease outbreak or epidemic-specific interventions. Applicants will propose innovations to incentivize CHRPs including but not limited to social marketing approaches that provide sales commissions or cash vouchers based on pre-negotiated performance milestones. Applicants will also propose criteria and systems for assessing functional capacity/capability of engaged CHRPs in line with national standards/expectations. Additionally, this Activity will support kitting and tooling of trained

CHRPs with job aids, stock and service data management tools, personal protective tools and other items as suited to the scope of services delivered and assigned tasks.

17 Refers to support to training, tooling, kitting, mentoring, supportive supervision, where applicable

16 Refers to support to training, tooling, kitting, mentoring, supportive supervision, where applicable

SIR 2.2: Provision of Culturally Acceptable and Gender-Sensitive Community Health Services

Improved.

To improve access to quality health services in the selected geographic areas, integrated outreach and mobile services should be provided in addition to static PHC facility service support that will be identified through the service delivery awards. Similar to the CBHWs, health services should be contextualized to be culturally-acceptable and gender-sensitive in targeted geographies. Innovative and/or proven approaches should be used to strengthen community-based service delivery, including facility-led outreaches, maternal and child health week, supplementary immunization campaigns etc. This activity will optimize service uptake for all outreaches including those led by both public and private (civil society and faith based) entities. This Activity will adapt and/or develop specific gender-transformative tools and/or checklists to critically analyze and improve service provision and associated health and nutrition outcomes with respect to men and women. This Activity will explore differentiated service delivery models, including those that can maximize the knowledge, practices and use of mission and traditional birth attendants (in non-delivery roles) and other locally valued health personnel within targeted communities. Where there are geographical overlaps, this Activity will ensure complementarity of proposed support to community-based health services with those led by other non-USAID funded donors or private organizations. Service provision and utilization should be monitored for any obstacle, deterrence and disenchantment to any particular group of persons.

SIR 2.3: Community-based surveillance and reporting of infectious diseases strengthened.

Nigeria’s health system continues to be challenged by multiple disease outbreaks, including but not limited to PZDs such as Lassa fever, rabies, and diseases of public health importance such as cholera, meningitis etc. In 2023 alone, Nigeria experienced multiple disease outbreaks across several states including Lassa fever, mpox, meningitis, diphtheria, cholera, Marburg, and yellow fever and was in the recovery phase for COVID-19. Coordinating surveillance systems, including at community level for the early detection and reporting of suspected cases of zoonotic diseases and other diseases of public health importance is a core objective of the revised National Action

Plan for Health Security (NAPHS). Strengthening CBS is a priority in underserved communities, where geographical access barriers or high cost of healthcare pose challenges to utilization, and health facility-based surveillance will remain an underestimation of the true burden of disease in these areas. This Activity will strengthen the capacity of CHRPs to identify and report suspected cases through appropriate and established government channels. Support will include developing CHRPs skills for the use of Nigeria’s Auto Visual Alert Detection and Reporting.

Community level providers will be supported to routinely, identify and report suspected cases, and may be primed for time and/or event-based surveillance informed by historical climate and disease burden data.

SIR 2.4: Bi-directional18 community-facility referral systems strengthened.

Effective two-way referrals, across all levels of care, are an essential component of accessible health care systems and are essential to save lives and ensure quality and a continuum of care.

Strengthening bi-directional or “two-way” community to facility referrals”,…