Reference_Attachment 1_ USAID Community Health Activity.pdf

Attachment 1 to USAID Community Health NOFO

PART A: Country Context With an estimated population of 227.8 million as of April 2024 (projections based on 2006 census), Nigeria has the largest population in Africa. Despite being one of the largest and fastest growing economies in Africa, Nigeria is home to the largest number of people living in extreme poverty in the world – about 85 million, or roughly 40 percent of the population (2023 State of World Population Report). Nigeria is divided into six geopolitical zones namely: North-West (NW), North-East (NE), North-Central (NC), South-West (SW), South-East (SE) and South-South (SS), each zone comprising states with similar ethnic groups and common political history. Nigeria practices a decentralized political system, mirrored in the health sector, made up of a three-tiered government structure. The structure is made up of a central federal government, 36 federating states and 774 local governments. Nigeria’s federated structure gives significant autonomy to the 36 states and the Federal Capital Territory, Abuja.

Nigeria is perpetually grappling with conflict tensions rooted in ethnic and regional rivalry, criminality, and competition for scarce resources. There are terrorist insurgencies in the NE, kidnapping and armed robbery rings in the NW, NC and southern regions, militant groups and criminal gangs in the SS, and conflict between farmers and pastoralists over access to land in the NC region. Drivers of conflict differ by geographic region and violence is often exacerbated by high levels of poverty, economic inequalities, and hardship. Conflict affects marginalized groups (women, children, religious minorities, and persons with disabilities (PWDs) differently. Arguably, women and girls are most impacted, as indicated in the distribution of internally displaced persons, particularly in the Northeast (Internal Displacement Monitoring Center 2019), and more marginalized from political and conflict mitigation processes, as well as the weight of deepened levels of Gender Based Violence (GBV).

A.1 Health Context Nigeria accounts for 2.4 percent of the world’s population but contributes 10 percent of the global maternal deaths1. The Nigeria healthcare system is constantly challenged with inadequate infrastructure, limited number of trained health care providers, and worsened by high burden of communicable and non-communicable disease with significant disparity across the regions. The NW and NE regions have the worst health indices (NDHS 2023-24). Access to health services is limited especially in rural areas with inequitable distribution of health facilities and health care providers.

National indicators are masked by regional variations and disparities by wealth quintile, education levels, age, urban/rural residence. National indicators are masked by regional variations and disparities by wealth quintile, education levels, age, urban/rural residence. For example, the Northwest (NW) and Northeast (NE) regions have the worst health indices (National demographic Health survey {NDHS} 2023-24), access to health services is limited in rural areas, only forty one percent of women with no education received antenatal care (ANC) services from a skilled provider, as compared with 95 percent of women with more than a secondary education. Similarly, uptake of skilled assistance during delivery also varies with only 22 percent of births in the NW region attended by a skilled provider, compared with 87 percent in the Southeast (SE). These variations by geographical regions and socio-economic status are also applicable to child health, malaria and nutrition indicators. For example, the 2023-24 NDHS found that advice or treatment was sought for 60 percent of children under age 5 who had symptoms of fever;

women with no education (54%) were less likely than those with secondary education (68%) to seek care just as women in the lowest quintile (50%) were less likely than those in the highest quintile (73%)

1 https://www.unicef.org/nigeria/situation-women-and-children-nigeria to seek care. Nutrition indicators have also worsened from the 2018 NDHS, with poorer outcomes for women with no education or in the lowest wealth quintiles. For example, stunted children are more likely to be in households where mothers have no education (55%) or in the lowest wealth quintiles (56%) compared to mothers with secondary education (29%) and in the highest wealth quintile (15%).

Power dynamics within households, especially in relation to decision making and economic means, also largely influence the time and place for seeking health care.

Family Planning and Reproductive Health: Over the last ten years, Nigeria has focused on expanding the FP method mix2, task shifting/sharing3 to increase the pool of health workers cadres who are able to provide long-acting methods and the deployment of a national family planning communication plan to increase exposure to evidence-based FP messages. In 2023-24, the NDHS found 15 percent of currently married women used any4 method of contraceptives. Between 2018 and 2023, total demand for family planning among currently married women increased from 36 percent to 41 percent and unmet need stood at 36 percent and 21 percent among sexually active unmarried women and currently married women respectively. Variations in the desired family size, total fertility rate (TFR), and contraceptive prevalence rate (CPR) exist among geopolitical regions and different socioeconomic levels. For example, TFR is highest in the NE (6.1 children per woman) and lowest in the SS (3.3 children per woman).

Similarly, demand for family planning is lowest in the NW (31 percent) and highest in the SW (63 percent).

Variation across and between regions and groups is driven by a range of factors including variable service access and quality, low exposure5 to FP messages, and sociocultural attitudes affecting desired family size and FP demand. A USAID funded behavioral sentinel survey (BSS) in October 2022 among over 3,000 women with a child under 2 years old living within SBC intervention wards in Kebbi, Sokoto, and Zamfara states found that emotional factors (such as injunctive & descriptive norms), and social factors (such as spousal communication, support) were predictive of FP use among couples, buttressing the need for continued investments in evidence-based SBC interventions. As part of efforts to expand access to FP products and services, Nigeria has implemented several innovative approaches including community-based distribution of contraceptives, mobile clinics and outreaches. This Activity will enhance these efforts and contribute to achieving objective two of Nigeria’s FP2030 commitment to increase FP access and choice through a total market approach, including community-level delivery using CHIPS or other volunteers.

Maternal Health: The proportion of women with four or more ANC visits reduced from 57 percent to 52 percent between 2018 and 2023-24. Between 2013 and 2018, the proportion of women with an ANC visit in the first trimester of pregnancy increased from 16 percent to 18 percent and a 10- percentage point reduction in the proportion of mothers with no antenatal care. The proportion of women receiving ANC from a skilled provider stood at 63 percent, decreasing by 4 percentage points between 2018 and 2023-24. These numbers are masked by disparities along rural/urban, geopolitical, and social status. For example, only 41 percent of women with no education received ANC services from a skilled provider, as compared with 95 percent of women with more than a secondary education. Additionally, due to women’s late registration for ANC and other factors, the gap between ANC-1 and ANC-4 uptake remains high.

5 65 percent and 56 percent of women and men respectively report no exposure to FP messages through any of the four media sources (radio, television, newspaper/magazine, and mobile phone) in the months preceding the NDHS 2018 survey.

4 includes modern and traditional FP methods.

3 Task shifting/task sharing policy for essential health care services in Nigeria as well as the standard of practice (SOP) (Federal Government of Nigeria 2018)

2 includes the introduction and scale up of hormonal IUDs, and a focus on FP self-care with the introduction and scale up of DMPA-SC https://knowledgecommons.popcouncil.org/focus_sexual-health-repro-choice/199/

Uptake of ANC services and facility-based delivery is influenced by a mix of internal, social, and structural factors. The 2022 BSS found internal enabling factors to include knowledge (specifically, women who knew at least one ANC benefit; knew to go to ANC at least four times; and knew to initiate ANC in the first trimester were 3.2, 2.1 and 1.2 times more likely to attend ANC 4+ times than those who didn’t);

self-efficacy (women with confidence in own ability to get to a facility were 2.5 times as likely to attend ANC 4+ times); beliefs and attitudes (women who believed ANC was effective or perceived childbirth services to be of quality were significantly more likely to attend ANC 4+ times) and social factors such as spousal support (women whose spouses supported their decision to attend ANC were 1.2 times more likely to attend ANC 4+ times). Documented barriers to ANC services included widespread misperceptions including that ANC is a curative and not preventive service; restrictive social and gender norms such as those that restrict women’s movements and social interactions or require spousal consent before leaving home; and structural wealth gaps e.g. women in lower wealth quintiles were 7 times less likely to attend ANC 4+ times than those in the top wealth quintiles – the single most important barrier to ANC uptake. These findings strengthen the case for continued investments in evidence-based SBC interventions and increasing access to services through community channels.

Maternal mortality ratio (MMR) remains high at 512/100,000 live births (2018 NDHS), accounting for over 10 percent of global maternal deaths. Many of these deaths occur outside of the health facility as nearly 6 in 10 births (57 percent) happen at home (NDHS 2023-24). Skilled assistance during delivery, a key factor in reducing maternal and neonatal mortality remains low with less than half (46 percent) of deliveries assisted by a skilled provider. As with many health outcomes, there is considerable variation by age group, geo-political zone, and mothers’ educational status. For example, the 2023-24 NDHS reported that births to mothers less than age 20 were more likely to be at home (67 percent) compared with older mothers (56 percent) as were births to mothers with no education (82 percent) compared to mothers with more than a secondary education (10 percent). Also, only 26 percent of births in the NW region are attended by a skilled provider, compared with 88 percent in the SE.

The 2022 BSS found positive shifts in behavioral drivers of facility-based deliveries. For example, the most cited reason for not delivering in a health facility – lack of a perceived need or “not necessary to go” -- declined in importance in all three states by between 16 and 31 percentage points. On the average, 6 in 10 women agreed that a health facility is the best place to deliver a baby and 5 in 10 reported intentions to deliver their next child at a health facility. Additionally, as with ANC, the study found husbands greatly influenced decision-making about facility delivery. These suggest amenability of enabling factors for uptake of facility-based deliveries to SBC interventions to modulate perceptions, and decision-making processes regarding birth planning. Despite approximately half of maternal deaths occurring within the first 24 hours after delivery, postnatal care (PNC) for mothers within two days of delivery remains low at 42 percent. The 2018 NDHS found that low awareness of the benefits of PNC in helping women recover from childbirth was a barrier to uptake, highlighting the need to integrate tailored SBC interventions to promote uptake of PNC services at community level.

Newborn Health: In Nigeria, 7 million babies are born annually6 and 250,000 die within the first month of life7. The country also has a high number of stillbirths, recording 171,428 in 20198. Over half of these

8 United Nations Inter-Agency Group for Child Mortality Estimation, 2019. Source: https://data.unicef.org/about-us/

7 UNICEF, ‘Every Child Alive,’ 11 July 2018. Source: https://www.unicef.org/nigeria/stories/every-child-alive-nigeria

6 UNICEF, Situation of Women and Children in Nigeria. Source: <https://www.unicef.org/nigeria/situation-women-and-children-nigeria https://www.unicef.org/nigeria/stories/every-child-alive-nigeria https://www.unicef.org/nigeria/situation-women-and-children-nigeria stillbirths occur in labor and childbirth and are mostly preventable9. Neonatal deaths are significant contributors (30 percent) to under five mortality (2018 NDHS). High rates of home deliveries with unskilled providers are a key driver of newborn deaths. The 2022 BSS reinforces this as it found newborn practices, including but not limited to skin-to-skin contact and cord care, improved among women who delivered in a health facility across all three states compared to those who birthed at home. Limited knowledge among women and families about newborn danger signs and poor health seeking behavior are other drivers of newborn deaths strengthening the need for continued SBC investments and community-based health services.

Child Health: Infant and Under-5 mortality rates are at 63 and 110 deaths per 1,000 live births respectively with only 39 percent of children aged 12-23 months receiving all basic vaccinations (NDHS 2023-24). The NDHS also reported that while care seeking for the largest contributors to child deaths improved (advice or treatment was sought for 60 percent of children under age 5 who had symptoms of ARI and diarrhea), prompt care (on the same or next day) remained low (only 29 percent and 50 percent of these children sought care promptly). The BSS found positive shifts in uptake of any vaccination, improved trust in health care worker and systems delivering RI, but reported persistent mistrust in vaccine efficacy/benefits, gaps in shared norms regarding vaccination and spousal opposition, signaling need for continued, targeted SBC interventions, including those that promote community and male engagement.

Nutrition: Malnutrition remains a serious public health and development concern in Nigeria, severely affecting the most vulnerable populations, especially children, adolescents, and women. NDHS 2023-24 found that among children under 5, about 40 percent are stunted; 8 percent suffer from wasting (low weight for height); and an estimated 27 percent are underweight. As with other indices, these numbers vary by geopolitical zones (with higher prevalence of wasting in the south south), rural-urban and socioeconomic quintiles. The 2022 BSS which sampled women exposed to USAID funded SBC programs reported positive shifts in cognitive (awareness of breastfeeding and its benefits) and social factors (spousal support) influencing the practice of exclusive breastfeeding while documenting persistent normative barriers (such as widespread practice of giving non-breastmilk liquids to a child in the first three days after birth). Similarly, the consumption of minimum dietary diverse meals by children under two improved by at least 20 percentage points among women exposed to community level interpersonal interventions, progress remains challenged by cognitive, normative, and structural factors.

Malaria: The 2021 Nigeria MIS reported a fever prevalence of 22 percent in children two weeks before the survey, down from 42 percent in 2010. The prevalence of malaria parasitemia in rural populations is

2.5 times that in urban populations (27 percent vs. 11 percent), and, when compared to the highest socioeconomic group, the prevalence among children in the lowest socioeconomic group is six times higher (31 percent vs. 5 percent). Access to, and use of insecticide treated nets (ITNs) is a priority prevention intervention and behavior. Nigeria’s use:access ratio dropped from 0.7 (DHS 2018) to 0.6 (MIS 2021) with wide variations from 0.3-0.8 across states, necessitating continued investments in tailored SBC interventions to address behavioral factors.

The 2021 MIS reported a 31- percentage point difference between children for whom care was sought (62.8 percent) and sought promptly10 (31.7 percent). Among children for whom advice or treatment was

10 Prompt care-seeking (within 48 hours of onset of symptoms) for febrile children is an evidence-based accelerator behavior.

9 World Health Organization (WHO), Reaching every newborn national 2020 milestones: country progress, plans and moving forward, WHO, Geneva, 2017, p. 17 sought, 45 percent and 31 percent sought from the public and private health sectors respectively.

Evidence suggests a mix of internal and social factors facilitate or create barriers to prompt care-seeking, many of which may be amenable to SBC interventions. Additionally, providers tested 24.3 percent of children with fever, for whom formal care was sought (from 14 percent in DHS 2018), suggesting continued room for behavioral interventions to improve health worker adherence to diagnostic and treatment guidelines.

Despite improvements in the uptake of IPTp3+ from 17 percent (DHS 2018) to 31 percent (MIS 2021), missed opportunities for increasing IPTp coverage remain justifying the need for community-level SBC activities to address behavioral barriers to early and consistent ANC uptake, improve pregnancy-related ideations, and increase IPTp uptake. Finally, evidence supports that the introduction of malaria vaccines, deployed alongside the continued uptake of other previously existing tools e.g. ITN, IPTp, SMC, increases intervention efficacy.

Tuberculosis: According to the World Health Organization (WHO), Nigeria has the highest TB burden in Africa, ranks sixth globally and is a high burden country for TB-HIV Co-Infection and Multidrug Resistant TB (MDR-TB). While the estimated incidence rate has remained the same (219/100,000 population) over the past ten years, the total estimated incidence has increased from 357,000 in 2010 to 479,000 in 2022.

Of the 479,000 estimated incident TB cases in 2022, about 71,000 (15 percent) were children, 27,000 (6 percent) were persons living with HIV (PLHIV), 12,000 (3.2 percent) had DR-TB and 125,000 (27 percent) people died from TB11. Following the United Nations high level meeting (UNHLM) in September 2023, Nigeria committed to the new targets including reaching 90 percent of people with TB prevention and care services, using a WHO-recommended rapid test as the first method of diagnosing TB; providing social benefit packages such as health insurance to all people with TB; licensing at least one new TB vaccine; and closing funding gaps for TB implementation and research by 202712. At the end of 2022, TB treatment coverage rate was 59 percent, notifying 282,184 new and relapse TB cases, a significant stride from 24 percent in 201813. The goal of the Mission TB Strategy is to help Nigeria make significant strides to accomplish the UN HLM targets and meet the WHO goals of ending the global TB epidemic by 2035 with a focus on strengthening case finding and treatment within the subpopulations with the largest gaps in treatment coverage - children and men of reproductive age.

Zoonotic diseases: In 2023 alone, Nigeria was faced with many re-emerging zoonotic, food-borne, and environmental-borne disease outbreaks such as Lassa fever, rabies, cholera, highly pathogenic avian influenza (HPAI), mpox, diphtheria, anthrax, bovine TB and yellow fever. This is despite the One Health strategy’s list of top five ranked priority zoonotic diseases (PZDs) of rabies, avian influenza, Ebola Virus Disease (EVD), swine influenza and Anthrax. Since 2021, USAID/Nigeria has supported risk communication systems strengthening, public facing risk communication and community engagement (RCCE) interventions targeting high risk populations for zoonotic diseases, contributing to improving Nigeria’s Joint External Evaluation (JEE) Scores across key RCCE indicators.

Social and Gender Norms: Gender roles, norms, and inequalities influence multiple health outcomes (e.g., risk for HIV, use/non-use of contraception, use of ANC and delivery services). As noted above, utilization of health care is affected by education levels, economic factors, and cultural beliefs and practices. Other determinants include knowledge about benefits and availability of health facilities and

13 FMOH NTBLCP 2022 Annual Report

12 WHO 2023. World leaders commit to new targets to end TB. United Nations high level meeting (UNHLM) in September 2023.

https://www.who.int/news/item/22-09-2023-world-leaders-commit-to-new-targets-to-end-tb

11 Nigeria Profile, WHO Global TB Report 2023 https://drive.google.com/file/d/13GpC9hx6lGx6DHf1TPd7wAPuVlV71kZj/view?usp=sharing https://docs.google.com/presentation/d/1oZxCEnEBOz5RsiOuKkQ1ZKecoBzc50bADq-f9jGTUzI/edit#slide=id.p https://www.who.int/news/item/22-09-2023-world-leaders-commit-to-new-targets-to-end-tb https://www.who.int/news/item/22-09-2023-world-leaders-commit-to-new-targets-to-end-tb services, perceived risk and susceptibility to an illness, gender and power dynamics, perceived quality of services including those related to negative provider attitudes and behaviors, and the health care system itself. For example, delay in seeking care (phase I delay) is a recognized contributor to adverse pregnancy outcomes in Nigeria. Factors such as cost of services, social status, health beliefs and personal characteristics of the users have been found to largely influence decision to seek timely obstetric care for pregnant women14.

The likelihood of seeking advice or treatment increases with a caregiver’s level of education and wealth.

Studies have continued to document that health-related knowledge does not translate to behavior change or increased utilization of services. For example, the main factors for giving pre-lacteals to babies are social norms, buttressing the need for SBC interventions that identify, deploy interventions to shift, and measure changes to social and gender norms.

Power dynamics within households, especially in relation to decision making and economic means, also largely influence the time and place for seeking health care. For example, only 34 percent of currently married women participate in three household decisions (regarding their own health care, household purchases, and visits to their family or relatives), while 37 percent are not involved in any of these decisions (NDHS 2018). Women’s participation in household decision making can be used to examine the relationship between women’s empowerment and selected health outcomes. For example, the more decisions in which women participate, the higher their contraceptive use (27 percent of women participating in all three decisions use a contraceptive method, as compared with 8 percent who do not). Additionally, several and widespread social norms enable gender-based violence (GBV), which in turn impacts on health seeking behavior and outcomes. For example, among ever married women, 36 percent report that they have ever experienced physical, sexual, or emotional violence. Of these, more than half of women (55 percent) have never sought help to stop the violence. Among those who do not seek help, their own families are the most common source of help. Finally, men tend to engage in less health-seeking behavior compared to their female counterparts because the primary health care system is perceived to cater to maternal and child health priorities—ANC, delivery, and routine immunization.

Despite these touch points in accessing care, there are a lot of missed opportunities to provide integrated RH services to men, women, adolescents, and children.

14 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943510/

PART B: Priority Development Challenges While weak health systems (inadequate infrastructure, limited number of trained health care providers) explain partly the gaps in the supply side, unhealthy behaviors and practices, diverse sociocultural and religious factors explain gaps on the demand side accounting for the poor health indices in Nigeria.

Furthermore, uptake of optimal preventive and health-seeking behaviors are low. There are varying levels of understanding of, when, how and where to obtain health services (health literacy). Service provider behavior can influence (positively or negatively) health seeking practices. People are treated as passive recipients of health and nutrition services. In addition, certain prevailing gender and social norms are barriers for healthy practices and behaviors. The limited levels of health literacy, health system literacy and healthcare seeking behaviors results in poor health outcomes, particularly for FP/RH, MNCH, TB, malaria, nutrition; sanitation and hygiene; and zoonotic diseases risk.

Therefore, this Activity will address a number of priority challenges to achieve the proposed results and contribute to broader population-level changes in health outcomes in targeted states. These challenges were derived from stakeholder consultations at national and subnational levels and lessons learnt from recent USAID/Nigeria investments and include:

● Continued misinformation and disinformation about health, health services and health products (e.g. vaccines)

● Limited end user/patient/client/community member engagement to drive evidence-based SBC campaigns

● Cultural factors and poor attitudes of health care providers towards pregnant women and their significant others or caregivers.

● Lack of adequate infrastructure, commodities and other supplies to support delivery of quality care

● Limited use of the full range of evidence-informed SBC approaches; specifically, an overreliance on communication-based approaches. To advance the field, the SBC community must continue to prioritize approaches that allow for improved efficiency or behavioral impact in a variety of settings and contexts. In Nigeria, many local organizations continue to rely on communication-based approaches, sparingly adopting newer, proven, or promising approaches such as behavioral economics, human-centered design (HCD) or information and communication technology, often at a limited scale. This Activity will need to support the SBC community to proactively seek out and test emerging and proven approaches from fields such as advertising, artificial intelligence (AI)/machine learning, psychology, neurosciences and establish mechanisms that support ongoing innovation.

● Inadequate application of norms and gender-transformative programming to address deep-rooted inequalities. Contextually (see Annex A), inequitable social and gender norms and power dynamics continue to restrict the participation and limit the agency of, particularly women, girls, and other marginalized groups in health decision making, access and uptake of lifesaving behaviors, services, and products. This Activity will advance the integration of evidence and learning on programming that seeks to transform social inequitable gender relations, power dynamics and shift norms that influence health behaviors throughout the program cycle. The goal will be to create an enabling environment for positive and sustained SBC and improved uptake of health services and products at the community level.

● Uneven capacity and opportunity among local actors to drive and sustain programming – market research has shown that there are many local organizations in Nigeria that have developed and are implementing their own health programs that USAID can support. For example, the report of a 2023 desk review to document capabilities of local organizations identified 308 local organizations, with 87 and 99 local organizations reporting some expertise and experience with https://breakthroughactionandresearch.org/resource-library/getting-practical-tool/#:~:text=When%20behavior%20change%20is%20a,is%20typical%20and%20appropriate%20behavior).

implementing SBC and health service delivery, including at community level respectively.

Additionally, preliminary analysis of the Mission-issued Localization in Health Request for Information, which received 225 responses from Nigerian local organizations, suggests varying levels of expertise and sufficient geographic spread in SBC and community health service delivery programming in Nigeria. Previous USAID investments in SBC capacity strengthening have been directed primarily at the public sector (government ministries, departments, and agencies).

An evaluation of these investments found incremental gains in capacity at individual (improved skills for planning, facilitating and monitoring SBC activities, for developing health messages, community mobilization), organizational (improved skills for SBC partner coordination) and systems level (increased state adoption and domestication of operational and orientation guidelines for ward level committee engagement in health).

● Insufficient integration of SBC into health systems to optimize health system performance and effect change of system actors - Provider behavior change (PBC) interventions remain an important and underused tool for improving health service quality, client satisfaction, and provider job satisfaction. The success of PBC interventions is often dependent on wider health system factors, such as organizational norms, supportive systems, and supervision, often driven by other health system actors. While continued attention is needed to maintain a focus on provider behavior, attitudes and norms, this Activity will deploy a health systems lens, expanding beneficiary lens to include health systems actors at managerial and governance levels, especially at the local government level.

● Inadequate and inconsistent measurement of behavioral outcomes and impact have hindered the assessment of program effectiveness and use of local data for evidence-based decision making – USAID/Nigeria has led ground-breaking SBC research investing in three rounds of cross-sectional behavioral sentinel studies, which collected extensive data on intermediate (or ideational) factors influencing thirteen RMNCH-NM behaviors among beneficiary households across three states in North West Nigeria. Data and findings from these studies, highlighted in the context section above, remains necessary for design and adaptive management purposes as well as improved understanding of whether and how SBC programming is effecting change in desired health outcomes. Consistent measurement, with the right rigor and frequency, will ensure catalytic investments in high-quality, effective SBC programming. Monitoring and evaluation approaches also need to be strengthened to better deal with complexity and to measure and monitor complex factors such as normative change.

● Gaps in country-led, coordinated SBC responses to mitigate recurring health shocks - on an annual basis, emerging and recurring health outbreaks and epidemics continue to pose disruptions to health services, product availability, systems, and outcomes. Effective responses, including for RCCE, to mitigate spread and impact often require interdisciplinary, coordinated multi-sectoral and gender-integrated approaches, yet the organization of Nigerian health systems remain fragmented, and capacity remains suboptimal, especially at sub-national levels.

Also, despite the clear and important role of RCCE in preparedness and response to health shocks, RCCE is often underfunded, undervalued, reactive (rather than proactive), and/or not data informed. Finally, the rapidly evolving nature of outbreaks often require adaptive programming approaches; the nuanced data needed to enable these approaches is often not intentionally generated, and competencies for adaptive management are weak.

● Untapped opportunities to understand and thoughtfully incorporate new technologies and media into SBC and Community Health programming – Harnessing the potential of digital platforms, mobile apps, and social media for improved programming both to expand access to services at community level or to expand reach and coverage of SBC interventions as well as monitoring (e.g., surveillance, data collection and management, and information exchange) remain largely https://grants.gov/search-results-detail/352091 https://grants.gov/search-results-detail/352091 https://knowledgecommons.popcouncil.org/cgi/viewcontent.cgi?article=1199&context=focus_sexual-health-repro-choice unexplored or untapped to its full potential. There is the need to build on and integrate such efforts into national systems to achieve sustainability. Development and uptake of new technologies is also fast paced, driven mostly by Nigeria’s tech savvy youth population, requiring public health practitioners to build media and digital literacy skills to keep up. While considering and exploring approaches to close the digital divide (e.g. male/female or urban/rural disparities), this Activity will pursue thoughtful innovations to incorporate new technology in ways that expand access, reach and coverage of community health and SBC interventions.

● Limited scale, coverage, and absence of a consistent approach to community-based health intervention programs – Community-based programs, often utilizing volunteer community workers to expand the availability and accessibility of primary health care services, information and products are not new to Nigeria. Recognizing the role of community-based approaches to achieving UHC, Nigeria launched its national community health influencers, promoters, and services (CHIPS) program in 2018 to harmonize existing community-based programs into one category of community-based health workers, served by one training curriculum and one M&E framework. Nigeria operates a decentralized health care system, with states having autonomy in the decision to adopt/adapt and scale implementation of national programs such as CHIPS.

Adoption of this promising program has remained suboptimal across states, have been mainly donor-funding dependent, with variations in approach (e.g. some states deployed CHIPs for single health areas/service e.g. malaria case management) and scale (e.g. CHIPs are deployed in a few local government areas). The NPHCDA is currently leading an ongoing evaluation of the success, challenges, and lessons from the CHIPs program with the intention to refine and redesign. The redesigned CHW program will greatly shape this Activity’s design and implementation of community-health strategies and approaches.

https://docs.google.com/document/d/1snRFllexRvkOOXQiQoMQ4BTHfDxQPNd3/edit#heading=h.gjdgxs

PART C: Activity Alignment with USAID and Government of Nigeria Priorities

Alignment with USAID Global and Mission Priorities This Activity will align with and advance the development priorities of USAID and the U.S. Government.

USAID’s work advances U.S. national security and economic prosperity, demonstrates American generosity, and promotes a path to recipient self-reliance and resilience, including in Nigeria. This Activity will advance the goals of key USAID health policies and initiatives, and global efforts detailed below.

Reproductive Empowerment and Family Planning USAID’s family planning and reproductive health (FP/RH) programming supports partner countries to realize a world where ongoing improvements to sexual and reproductive health (SRH) contribute to longer, healthier, and more prosperous lives for all. To reach this transformational destination, USAID Nigeria supports three rights-based pathways, articulated by USAID Pathways to Progress, that collectively operate at societal, systems, and individual levels. These pathways include:

1) SBC interventions to a) enable individuals, couples and communities to have accurate information, skills, and ability to decide, voice, and act on their reproductive intentions and achieve the highest attainable levels of SRH across their lifetime and b) strengthen local communities, organizations, institutions, and governments to create and foster social norms and policies that support individuals to make and act on their own SRH decisions, free from violence, coercion, and discrimination;

2) Service readiness and health systems strengthening support to increase quality and access to people-centered sexual and reproductive healthcare; and

3) Contraceptive commodity security through data-informed forecasting, quantification, procurement and distribution of SRH/FP commodities, including to the last mile.

This activity will advance the SBC pathway, including support to cross-cutting best practices such as youth engagement and integration in programming and gender-transformative programming (i.e., programming that addresses the root causes of gender inequalities and transforms gender relations to promote equality and achieve FP/RH objectives. Given Nigeria’s demography and youth bulge, youth-centered programming is particularly important to enable adolescents to delay childbearing and to contribute to improved economic, social, and health outcomes for adolescent girls and boys and their communities. Meaningful, participatory engagement and programming will include a focus on underrepresented groups, indigenous groups, and racial and ethnic minorities. Finally, this activity will continue to support the FP2030 partnership and hub including the government, donors and multilateral agencies, civil society organizations, and private sector entities working together to advance family planning in Nigeria.

Maternal, Child Health and Nutrition In the last 30 years, USAID has contributed to progress in improving maternal and child survival, across the world and in Nigeria but gaps remain (see section in Nigeria context). In March 2023, Administrator Power released the Agency’s Preventing Child and Maternal Deaths (PCMD) Framework, which provides the overarching direction of USAID’s MCH program. Through this framework, USAID will work to reduce preventable child and maternal mortality in 25 countries, including Nigeria, to 12 percent or lower of total deaths by 2030. USAID/Nigeria’s MCH support is guided by, and aligns with the six strategic approaches including: anchoring our response in primary health care systems to optimize health outcomes; reaching the hardest to reach mothers and children; identifying and tailoring solutions through locally-led development; investing in the health workforce as the foundation of health systems;

catalyzing country commitment; and generating and using data and evidence in decision making. The https://drive.google.com/file/d/1hklWoC5UvecyqoCuFnBYW8sux7rgziXn/view?usp=sharing https://www.fp2030.org/ https://www.usaid.gov/sites/default/files/2023-03/Preventing%20Child%20and%20Maternal%20Deaths%20A%20Framework%20for%20Action%20in%20a%20Changing%20World%202023-2030_508c.pdf

Maternal and Child Health and Nutrition (MCHN) Technical Roadmap further focuses on the pillars of coverage, quality, and equity and articulates a measurable results framework. The Roadmap guides USAID Nigeria on priority actions to support the achievement of 2030 Sustainable Development Goals (SDGs) for mothers, newborns, and children. The Roadmap acknowledges the centrality of behaviors and norms to support healthy individuals and communities. This activity will contribute to the achievement of priority areas for MCHN SBC investments including efforts to improve quality of care including respectful care, provider behavior change, and demand for MCH services.

USAID’s Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality (EPMM) are global action plans supported by a multi-partner group to strengthen synergy and coordination of actions at the global and country level to accelerate reductions in maternal and newborn mortality and to prevent stillbirth. The International Maternal Newborn Health Conference (IMNHC) in Cape Town in May 2023 heralded the launch of the first Joint ENAP-EPMM Progress report which highlighted coverage targets and milestones (renewable every two years) and stimulated the development of 28 ENAP-EPMM country acceleration plans, including for Nigeria, that identified priority actions to achieve the targets.

Child Survival Action (CSA) works alongside EPMM and the ENAP to address mortality across the lifecourse. Nutrition interventions directly contribute to ENAP-EPMM-CSA goals. This activity will contribute to efforts to strengthen community platforms for the delivery of high impact interventions essential for maternal, newborn and child survival, and to reduce fragmentation/optimize available resources.

In 2021, the U.S Congress passed the Global Malnutrition Prevention and Treatment Act, which directs USAID to prevent and treat malnutrition globally. USAID’s Implementation Plan serves as a roadmap for USAID’s investments in the prevention and treatment of malnutrition for the period from October 2022 to October 2029. A number of health-related nutrition behaviors which are vital to improve nutrition outcomes are highlighted in this plan. USAID/Nigeria’s Multi Sectoral nutrition strategy and Action Plan (2022–2026) addresses the prevention of all forms of undernutrition, with emphasis on those that target the "1,000 day window of opportunity" from pregnancy through a child's second birthday – a period in which good nutrition is critical for optimal physical and cognitive development. Expanding access though community health services as well as SBC for improved nutrition behaviors15 is a key aspect of this strategy. This activity will build on recent mission investments in SBC for nutrition that have focused on improving the quality of SBC design, implementation, and measurement. Applying innovative techniques that have proven successful in other sectors to nutrition in the health sector to accelerate progress in preventing malnutrition is a priority area for this activity.

Malaria The past two decades have seen extraordinary progress in malaria control efforts globally. The World Health Organization’s (WHO) 2022 World Malaria Report estimates that more than 10.6 million malaria deaths and 1.7 billion malaria cases were averted worldwide between 2000 and 2020. During that same time period, many countries, including Nigeria, have made notable progress towards subnational or national malaria elimination. For example, fever prevalence reduced from 42 percent to 22 percent among children between 2010 and 2021. Despite these achievements, progress has been uneven and has fallen short of global and national goals and targets. The U.S. President’s Malaria Initiative 2021-2026 Strategy: End Malaria Faster articulates a vision for how PMI will contribute to the global goals of saving more than four million lives and averting over 1 billion cases by 2025. The Strategy

15 Early initiation of breastfeeding and exclusive breastfeeding up to six months; appropriate complementary feeding; increased dietary diversity for children 6-24 months; and increased dietary diversity for pregnant women https://www.usaid.gov/sites/default/files/2022-12/USAID_MCHN_RoadMap_V12c_SINGLE_508%5B46%5D%20%281%29_1.pdf https://www.who.int/initiatives/every-newborn-action-plan https://www.who.int/initiatives/ending-preventable-maternal-mortality https://www.childhealthtaskforce.org/hubs/child-survival-action https://www.usaid.gov/nutrition/resources/usaid-resources/global-malnutrition-implementation-plan https://docs.google.com/document/d/1xWwfJInbWeJG-_dUhAMMRbvQcjDjPMzX/edit?usp=drive_link&ouid=109264426303088824095&rtpof=true&sd=true https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022 https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2021/10/10.04Final_USAID_PMI_Report_50851.pdf https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2021/10/10.04Final_USAID_PMI_Report_50851.pdf maintains the broader orienting goal to work with 30 PMI partner countries, including Nigeria to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination and includes five core focus areas: reaching the unreached; strengthening community health systems; keeping malaria services resilient; investing locally; and innovating and leading. Achieving the goals and objectives outlined in the End Malaria Strategy will require coordinated and innovative behavioral programming to achieve optimal uptake of current and emerging malaria interventions e.g.

malaria vaccines among affected communities and the providers who serve them. This activity will build on lessons from nearly a decade of mission investments in proven and emerging malaria SBC approaches in Nigeria to scale up implementation while continuing to innovate.

HIV/AIDS

The United States Government (USG) is leading other donors and governments to coalesce around its ambitious goal of controlling the HIV epidemic and ending HIV/AIDS as a public threat by 2030. The U.S.

President’s Emergency Plan for AIDS Relief (PEPFAR) is the U.S. government’s initiative to help save the lives of those infected and affected by HIV/AIDS around the world. In Nigeria, PEPFAR seeks to end HIV/AIDS as a public threat by 2030 by furthering the achievement of the 95-95-95 targets through accelerating core interventions for epidemic control, with particular emphasis on impact; efficiency;

sustainability; partnership; and human rights. To reach these targets, PEPFAR recognizes and has identified behavioral science as a key component in its 2023-2028 strategy. Achieving the 95-95-95 targets will require effectively addressing related social and behavioral factors affecting demand for biomedical prevention methods such as Pre-Exposure Prophylaxis (PrEP) and voluntary medical male circumcision (VMMC), HIV testing, treatment initiation, and continuity and adherence to HIV treatment.

This activity will advance areas of particular interest in Nigeria which include but are not limited to closing inequity gaps (e.g. lower case finding among men and children), addressing last mile and persistent challenges (such as lower adherence to HIV treatment among adolescents and young adults), and supporting the introduction of longer acting treatment and new options for PrEP.

Tuberculosis USAID leads the US Government’s efforts to combat TB in collaboration with stakeholders and partners around the world. The USAID Global TB Strategy (2023 -2030) articulates the “ vision, mission, goals, results framework, strategic objectives, and principles to contribute to partners’ collaborative efforts to meet upcoming United Nations HighLevel Meeting on TB targets, end the TB pandemic by 2030, and eliminate TB by 2050”16. The strategy contributes to the goals of the WHO’s End TB Strategy as well as the SDGs. Nigeria is one of the 24 high burden countries that USAID provides bilateral assistance and supports National TB Programs with their TB control efforts. USAID’s evidence-based expansion of its reach, cure, prevention and innovative approach is implemented through a mix of Technical Assistance and Direct Service Delivery interventions which are then scaled up by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GF ATM). Achieving the UN HLM targets in the complex and under-resourced Nigerian health sector requires an intentional focus on doing-more-with less while seeking to address the social factors that influence the spread of TB and those that affect care seeking for those with symptoms. Programming will focus on improving uptake of services among priority populations, reducing pre-treatment loss to follow-up or refusal of treatment, improving treatment adherence and improving TB preventive practices as well as uptake of TB preventive therapy.

Global Health Security Around the world, millions of people have lost their lives and livelihoods because the world lacked

16 USAID Global TB Strategy 2023 - 2030 https://www.pmi.gov/where-we-work/ https://www.state.gov/ending-hiv-aids-as-a-public-health-threat-by-2030/ https://www.state.gov/pepfar/ https://www.state.gov/pepfar/ https://www.state.gov/wp-content/uploads/2022/11/PEPFARs-5-Year-Strategy_WAD2022_FINAL_COMPLIANT_3.0.pdf https://www.usaid.gov/sites/default/files/2022-12/SinglePage-USAIDTB-StratDoc-For508.v3.pdf https://www.who.int/publications/i/item/WHO-HTM-TB-2015.19 capacity to prevent, detect, and respond to COVID-19 and other emerging infectious disease threats.

USAID’s Global Health Security (GHS) Program seeks to prevent and mitigate the increasing occurrence and severity of epidemics, pandemics, and other emerging infectious disease threats. USAID partners with countries, including Nigeria to build and strengthen local partnerships and develop measurable sustainable capacity to adopt evidence-based and innovative solutions to prevent, rapidly detect, effectively respond to, and ultimately recover from emerging infectious disease threats – whether naturally occurring, accidental, or deliberate. USAID/Nigeria advances the implementation of the One Health approach, recognizing the connection between the health of the environment, animals, and people, bolstering the GHS architecture; and building resilience in concert with USAID’s broader global health programs.

This activity will support Nigeria to achieve demonstrable increase in capacity in at least one of five 5 key GHS technical areas, risk communication and community engagement (RCCE), in alignment with the relevant priority indicators as defined in the Joint External Evaluation (JEE) 3rd edition.