Request for Information (RFI) 72036724RFI00003_USAID Better Health.pdf

REQUEST FOR INFORMATION (RFI)

ISSUANCE DATE: April 19, 2024

RFI CLOSING DATE: May 03, 2024, 5:00 PM Nepal Time

SUBJECT: Request for Information (RFI) 72036724RFI00003 – USAID Better Health

Dear Prospective Respondents and Interested Parties, The United States Government, represented by the U.S. Agency for International Development (USAID) in Nepal, is designing a new activity entitled USAID Better Health. USAID is publishing this Request for Information (RFI) pursuant to FAR 52.215-3 to conduct market research, gauge interest from qualified organizations, and seek public comments, clarifications, and suggestions on the DRAFT Statement of Work (SOW). This announcement is an RFI issued solely for information and planning purposes and does not constitute a Request for Proposals (RFP). Responses to this RFI are not binding on the U.S.

Government and do not obligate USAID to issue a solicitation, nor do they commit USAID to pay any cost incurred in the preparation and submission of comments and responses.

Brief Activity Description The USAID Better Health activity is designed to support the Government of Nepal (GoN) in its continued progress towards achieving the Sustainable Development Goal (SDG) of Universal Health Coverage (UHC), which includes access to quality, essential health services, especially for the most marginalized. It aims to strengthen Nepal’s health system to improve maternal, newborn, child health, and family planning (MNCH/FP) outcomes in partnership with the three tiers of government. The activity will collaborate with a range of stakeholders including communities, the private sector, and professional organizations to achieve its objectives. Core objectives will include: improve health governance, increase community accountability and responsiveness, improve quality of care, increase access for marginalized communities, and enhance the health system’s resilience and response to emergency health needs.

Instructions In order to inform the design and maximize potential program impact, USAID invites constructive feedback on the draft SOW (Attachment A). USAID strongly encourages responses from all types of organizations, firms, and individuals in order to receive a diversity of feedback. These comments will be taken into consideration in the design of the final activity. In addition to general feedback, USAID would like to receive comments related, but not limited, to the questions listed below:

1. Is the SOW clear? What feedback or suggestions do you have to improve the draft SOW?

2. Do you have any specific suggestions or feedback on the result framework?

3. USAID is considering a cost-plus-award-fee type contract to motivate exceptional performance while providing the Government with the flexibility to evaluate both actual performance and the

U.S. Agency for International Development (USAID) G.P.O. Box 295 U.S. Embassy, Maharajgunj Kathmandu, Nepal Telephone: +977.1.423.4000 Email: usaidnepal@usaid.gov Website: https://www.usaid.gov/nepal mailto:usaidnepal@usaid.gov https://www.usaid.gov/nepal

Request for Information (RFI) 72036724RFI00003 : USAID Better Health conditions under which it was achieved. USAID welcomes feedback on the possibility of using this contract type, or suggestions on other contract types that might be appropriate.

4. USAID is interested in industry suggestions on the type of procurement approach that should be utilized, including any suggestions on applicable indefinite-delivery, indefinite-quantity (IDIQ) contracts you are aware of that USAID/Nepal could use to issue a task order for this mechanism.

Please provide suggestions on the potential procurement approach that you recommend along with your rationale.

5. Is there any other feedback you would like to provide?

Sources Sought Information USAID/Nepal further seeks to determine the capabilities and interest of qualified organizations.

Interested parties who consider themselves qualified to implement the activity are invited to submit information supporting their experience, expertise, and capabilities in undertaking similar work as follows:

1. Organization Information: Name, email address, address, small business status (if applicable), GSA OASIS Pool holder details (if applicable), or any other IDIQ holder details as applicable.

2. Maximum three-page capability statement describing your organization’s ability to execute the services in the draft SOW attached.

3. One-page table that contains a list of up to five past or current projects/activities that detail your organization’s experience of performing efforts of similar size, scope, and complexity as the requirements detailed in the attached draft SOW (Attachment A). Sample format below:

Name of Activity Country Years (From-To) Brief Description

Responses to this RFI neither constitute applications nor form a binding agreement. USAID again reiterates that any commentary provided in response to this RFI will not advantage any organization with respect to any subsequent procurement. Lastly, USAID/Nepal may use submitted responses without restriction or limitation. No feedback will be provided to organizations regarding their submissions.

Instructions: Responses to this RFI must be submitted via email to the Contracting Officer, Maria Televantos at mtelevantos@usaid.gov with a copy to the Acquisition and Assistance Specialist, Chetana Ghimire at cghimire@usaid.gov with the subject entitled: “Request for Information (RFI) 72036724RFI00003 : USAID Better Health” no later than the date and time stated above.

Thank you for your interest in the subject request for information.

Sincerely, Maria Televantos Contracting Officer mailto:mtelevantos@usaid.gov mailto:cghimire@usaid.gov

ATTACHMENT A - DRAFT STATEMENT OF WORK OF USAID BETTER HEALTH

C.1. ACTIVITY TITLE

USAID Better Health

C.2. PURPOSE AND OBJECTIVES

The purpose of USAID Better Health is to strengthen Nepal’s health system to increase access to, and use of, quality health services especially by marginalized communities. The purpose will be achieved through following objectives: 1. Improve health system governance, 2. Increase health system accountability and responsiveness to marginalized communities, and 3. Improve quality of targeted health services for marginalized groups. The contract supports the Government of Nepal (GON) in its continued progress towards achieving the Sustainable Development Goals (SDGs) of Universal Health Coverage (UHC) and access to quality essential health-care services especially for the most marginalized.

C.3. BACKGROUND

C.3.1. Relevant Nepal Health Sector Overview

Over the past few decades, Nepal has made significant progress in MNCH and FP. Between 1990 and

2015, Nepal reduced its maternal mortality ratio by 71% from 901 deaths per 100,000 live births to 288

(World Health Organization). In 2016, the maternal mortality ratio was estimated at 239 per 100,000 live births1 which was reduced to 151 per 100,000 live births in 20212. However, disparities in maternal mortality still exist across provinces, with Lumbini at 207 deaths per 100,000 live births, Karnali at 172, Madhesh at 140, and Bagmati at 98 deaths per 100,000 live births2. Most of the maternal deaths (61%) were in the postpartum period, while 33% occurred during pregnancy and 6% during delivery; 57% of deaths were in health facilities with 26% of deaths at home2, indicating that women are using health facilities for delivery, but that health facilities are not adequately prepared to manage complications. The same study has shown that among the women who died during delivery and in the postpartum period, 76% had delivered at a health facility; among those, 62% had delivered at government health facilities and 38% at a non-government health facility. This data is also supplemented by Nepal Demographic and

Health Survey (NDHS) 2022 data, which shows that 79% of live births were in a health facility, with 62% in the public sector, and 17% in a private health facility. All these data indicate an urgent need to improve the quality of maternal health services at health institutions in order to achieve the SDGs on maternal mortality.

2 MoHP, NSO. (2022). National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021.

Kathmandu: Ministry of Health and Population; National Statistics Office.

1 Ministry of Health, Nepal; New ERA; and ICF. 2017. Nepal Demographic and Health Survey 2016. Kathmandu, Nepal: Ministry of Health, Nepal.

Similarly, in Nepal, infant mortality decreased by more than two-thirds from 78 to 28 deaths per 1,000 live births in 1996 and 2022 respectively. In the latest NDHS 2022 survey, under-five mortality declined threefold, from 118 to 33 deaths per 1,000 live births. However, over the last ten years disparities persist in under-5 mortality rates, which is higher in rural areas (38 deaths per 1000 live births) compared to urban areas (30 deaths per 1000 live births); and lowest in Gandaki Province (23 deaths per 1000 live births) to highest in Sudurpaschim Province (49 deaths per 1000 live births). Furthermore, for the last 10 years neonatal mortality has remained stagnant at 21 per 1,000 live births. Eighty-five percent of all deaths among children under age 5 in Nepal take place before a child’s first birthday, with 64% occurring during the first month of life3. There is very little data on causes of child mortality in Nepal, it is thought that a majority of child deaths align with global causes including: pneumonia and diarrheal diseases.

Family planning has also stagnated in recent years; according to the 2022 NDHS, 57% of married women aged 15-49 years use any method of family planning, and 43% use a modern contraceptive method. The use of modern methods is lowest in Gandaki Province at 35%, and highest in Sudurpaschim Province at

47%. The total fertility rate has been declining in Nepal from 4.6 in 1996 to 2.1 in 2022, with higher fertility rates among adolescents and low wealth quintile groups, however, 21% of married women still have an unmet need for family planning, including 13% who do not want any more children and 7% who want to delay childbearing.4 Furthermore, there is scant data on youth and unmarried women and their family planning needs. There is limited access to youth friendly reproductive health services in the public and private sectors. Some social marketing approaches undertaken by the GON have increased access to longer-term methods such as injections and IUCDs. Child marriage is prevalent yet largely undocumented. The median age at first marriage is 18.3 years, with 16.5 years for Muslim ethnic groups compared to 19.2 years for Janajati ethnic groups. Furthermore, 12% of women aged 25-49 were married at age 15. Marriage at an earlier age is more prevalent in Madhesh Province (16.6 years) compared to Bagmati Province (19.9 years) (NDHS 2022). Moreover, 23% of women, aged 15-49, have experienced physical violence since age 15 with the highest rates in Madesh province (36% experienced physical violence).

Water Sanitation and Hygiene (WASH) practices remain suboptimal. In a recent nationally representative health facility-based survey, almost 97% of health facilities had soap and running water or alcohol-based hand disinfectant, however, only 7% had infection prevention and control guidelines and 1% of health facilities had all infection prevention and control items (Nepal Health Facility Survey [NHFS] 2021). In addition, 7% of the population practice open defecation (NDHS 2022). The suboptimal WASH practices have implications for infection control and quality of care in MNCH and FP services.

4 Ministry of Health and Population, Nepal; New ERA; and ICF. 2022. Nepal Demographic and Health Survey 2022:

Key Indicators Report. Kathmandu, Nepal: Ministry of Health and Population, Nepal.

3 Ministry of Health and Population, Nepal; New ERA; and ICF. 2022. Nepal Demographic and Health Survey 2022:

Key Indicators Report. Kathmandu, Nepal: Ministry of Health and Population, Nepal.

Progress made in the last decade is largely attributable to government and partner efforts towards designing and scaling-up targeted, high-impact, and evidence-based MNCH and FP interventions at facility and community levels, including increasing service delivery outlets and platforms to improve access. The Government’s maternity care incentive program, providing free childbirth services (with travel costs covered for antenatal care and delivery services at health facilities) coupled with the free newborn care programs at health facilities has been a major driver of increased institutional births.

In 2020, the COVID-19 pandemic and its aftermath threatened Nepal’s health gains by disrupting routine health service delivery and over-stretching the health system. Through collaborative efforts between the

GON and external development partners, Nepal achieved remarkable progress in containing the effects of the COVID-19 pandemic and its consequences. As a result, the emergency response system across three tiers of government was strengthened. However, the GON’s capacity to prevent and respond to future pandemic threats remains insufficient.

C.3.2. Sectoral Challenges and Opportunities

Nepal’s transition to federalism is still evolving and the health system continues to face numerous challenges, including: poor coordination across the three tiers of government with ambiguous provincial and district roles; limited policies and strategies targeting marginalized communities (especially at the local level); continued suboptimal use of data for planning and budgeting; limited and declining resources for health at all levels; and gaps in the capacity of health workers and municipal managers to plan and implement health interventions. Despite recent and substantial progress across multiple health indicators in Nepal, major barriers to equitable access to quality health services, including maternal, neonatal and child health (MNCH) and family planning (FP) services remain.These challenges are also opportunities to strengthen federalism, and to bring health services closer to, and tailored for, communities in need.

Current health system resilience, surveillance, and natural disaster response systems remain verticalized.

There are opportunities to harmonize and strengthen coordination between and among the Health

Emergency Operation Centers (HEOCs), Rapid Response and Medical Deployment Teams, and the Early

Warning and Reporting System (EWARS). Moreover, integration of climate adaptation and mitigation in health systems work is critical to build a responsive health system in the context of federalism and recurring natural disasters.

C.3.3. Health System Support in Nepal

Nepal has had significant donor investment in the health system, to promote maternal and newborn health, FP, and WASH. Significant donors include: USAID, the World Bank, WHO, FCDO, GIZ, and UN agencies. With the GON taking a leadership role in defining and implementing health systems strengthening, the donor landscape is shifting. For over two decades, health systems strengthening has been a central focus of USAID’s investments, with major flagship projects, including: Nepal Family Health

Program (NFHP I), Nepal Family Health Program II (NFHP II), Health for Life (H4L), and Strengthening

Systems for Better Health (SSBH), contributed significantly to Nepal’s health system improvements.

Pre-federalism, NFHP I (2002-2007) and NFHP II (2007-2012) supported the GON to make progress towards the Millennium Development Goals of reducing child and maternal deaths by strengthening

MNCH and FP health service delivery at the national, district, facility, and particularly at the community levels. NFHP I and NFHP II placed emphasis on supportive supervision and strengthened the GON’s stewardship and oversight roles of public sector service delivery. NFHP II was built on the successes of

NHFP I, and it continued to generate evidence to support scale up of new approaches to reducing maternal and child mortality and morbidity, expanded the use of FP and reproductive health services, and increased the availability of essential medicines and commodities at the community and health facility levels.

The successor to NHFP II, H4L (2013-2017), strengthened HFOMCs and continued to improve the quality of MNCH and FP services. H4L strengthened the GON’s capacity to plan, manage, and deliver high-quality and equitable MNCH and FP services in western Nepal and also partnered with GON following the 2015 earthquake to respond for recovery and HSS in the hard-hit districts of central Nepal. The SSBH activity

(2018-2024) is strengthening the health system in the evolving federal context, primarily in Karnali and

Lumbini provinces. The SSBH final evaluation5 showed the effectiveness of activity-supported approaches of customized HSS capacity-building TA aimed at empowering and creating ownership among local stakeholders, and institutionalizing quality of care (QoC) practices through local governance and management capacity building. The activity has strengthened data-driven planning/budgeting and governance at the municipal level in intervention areas. However, persistent challenges of inadequate infrastructure and human resources continue to affect health services and limit the effectiveness of interventions. In its final year, SSBH is also focused on supporting the operationalization of USAID’s direct-to-government, on-treasury support, (also known as government-to-government (G2G) in Karnali

Province and its three municipalities (Birendranagar, Bheriganga and Gurans).

USAID’s G2G on-treasury support is currently implemented at the federal level, Karnali Province and in the three municipalities stated above, with plans to expand to additional municipalities and provinces. To improve health outcomes for mothers and babies, USAID also partners with the MOHP through other activities such as USAID Adolescent and Reproductive Health (ARH), the MOMENTUM Country and

Global Leadership (MCGL) and the UNICEF Maternal Child Health (MCH) umbrella grant. ARH works with both the public and private sectors to improve reproductive health and family planning outcomes among adolescents. MCGL builds national capacities to improve the quality of care for mothers and newborns in

Koshi and Bagmati provinces. The UNICEF MCH umbrella grant is focused on promoting breastfeeding and improving lactation support in health facilities. The new Integrated Nutrition Activity will improve the nutrition status of women, adolescents, and children in Nepal’s underserved and marginalized communities. USAID Nepal has also recently launched a suite of Global Health Security (GHS) activities

5 Final Evaluation of the Strengthening Systems for Better Health (SSBH) Activity, October 2023 https://pdf.usaid.gov/pdf_docs/PA021F7R.pdf https://pdf.usaid.gov/pdf_docs/PA021F7R.pdf which aim to strengthen the GON’s capacity to prevent, detect, and respond to public health emergencies by strengthening multi-sectoral approaches to: 1) prevent antimicrobial resistance; 2) prioritize zoonotic disease prevention and response; 3) improve laboratory systems and surveillance for timely detection; and, 4) strengthen health emergency preparedness and management for rapid and effective response to outbreaks. These GHS activities will be implemented at all levels of government.

USAID and Gavi, the Vaccine Alliance, coordinate for greater vaccine coverage in Nepal. The Centers for

Disease Control and Prevention (CDC) does not currently have a presence in Nepal, but USAID facilitates

CDC’s coordination and collaboration with the Ministry of Health and Population (MOHP) and other partners on the implementation of field epidemiology training and other, largely research-focused work.

USAID also supports the MOHP’s polio eradication program through the World Health Organization

(WHO).

C.4. RELATIONSHIP TO USAID NEPAL CDCS and GOVERNMENT OF NEPAL STRATEGIES

USAID Better Health will contribute primarily to the health component of USAID Nepal’s Country

Development Cooperation Strategy (CDCS) DO 3: “Inclusive health & education systems strengthened,” particularly IR 3. 1 “Quality of health and education services improved,” through improved coverage and quality of health care services especially of MNCH and FP services; IR 3. 2 “Equitable access to health and education services improved,” through improved health governance, increased community accountability and responsiveness, and targeted approaches to reach marginalized communities; and IR

3. 3 “Health systems’ capacity to prepare for and recover from shocks increased,” through improved governance, improved resilience, and better prepared mechanisms to respond to health emergencies.

This activity will also contribute to advancing the CDCS cross-cutting themes of federalism, inclusion, resilience, and the Agency's locally led development agenda.

The Constitution of Nepal (2015) has provisioned that “every citizen shall have the right to free basic health services from the State, and no one shall be deprived of emergency health services” and that

“every citizen shall have equal access to health services”. With the goal of advancing Universal Health

Coverage, Nepal’s NHS-SP is aligned with the 2019 National Health Policy commitment to provide basic health services for every Nepali citizen by increasing access to an equitable, accountable, and quality health system.

The NHS-SP also operationalizes the GON’s international commitments including Nepal’s Development

Cooperation Policy (2019), the Paris Declaration on Aid Effectiveness (2005), the Accra Agenda for Action

(2008), the Busan Partnership for Effective Development Cooperation (2011), as well as the Statement of

Intent to Guide the Partnership for Health Sector Development in Nepal and the International Health

Partnership National Compact (2009). This activity will support the NHS-SP in the areas of institutionalizing health system governance, enhancing social accountability in the health sector, and ending preventable deaths.

https://drive.google.com/file/d/1AH8y5NnqqYmYSNrZa5zfQBahGj18Dxjk/view

The GON is committed to achieving the SDG 2030 goals (MMR or 70 per 100,000 births, NMR of 12 per

1,000 live births, and under five mortality of 25 per 1,000 live births) and ensuring universal access to sexual and reproductive health-care services, including FP, information and education, and the integration of reproductive health into national strategies and programs. To achieve these goals the GON has developed the Safe Motherhood and Newborn Roadmap 2030, the Nepal Every Newborn Action

Plan (NENAP 2016) and has made commitments, including to the FP 2030 and FP Costed Implementation

Plan 2023-2030 (in the process of finalization), focusing on equitable access to and utilization of quality maternal, newborn and FP.6

This activity will advance institutional and sustainable approaches via health system strengthening (HSS), and flagship MNCH and FP activities, to ensure quality health service utilization by those most in need.

The USAID Better Health activity will partner with Nepal’s three tiers of government in their continued progress towards achieving UHC and the 2030 Sustainable Development Goals (SDGs). The activity will collaborate with the GON to achieve the results envisioned in the Nepal Health Sector-Strategic Plan

(NHS-SP): 2023-2030 with a specific focus on strategic objective 1: Enhance efficiency and responsiveness of the health system and strategic objective 4: Promote equitable access to quality health services. Specifically, the award will support systems improvement to increase collaboration, planning, and budgeting across all three tiers of government; establish accountability systems that prioritize the needs and preferences of marginalized communities; and improve healthcare service quality.

C.5. THEORY OF CHANGE

Purpose: To support the GON in its continued progress towards achieving the Sustainable Development

Goal of universal health coverage and access to quality essential health-care services, especially for the most marginalized.

If

Governance is enhanced through effective collaboration across the three tiers of government and responsive planning and budgeting, And

Accountability is instituted through greater engagement of marginalized community stakeholders, And

Provider capacity and service quality is improved, Then

The health system will be strengthened to increase inclusive access to quality health services.

C.6. RESULTS FRAMEWORK

6 The resources referenced in this paragraph can be found here: https://digitallibrary.fwd.gov.np/ https://digitallibrary.fwd.gov.np/

C.7. TECHNICAL APPROACH

Health systems require good governance, accountability and responsiveness to ensure optimal access to quality care for all.

Objective 1: Improved health system governance.

A broad definition of governance is applied here, that includes efforts that improve leadership and management capacity at all levels of the health system. Governance reinforces a strong policy environment focused on successful implementation, learning, and adaptation across three levels of government. A comprehensive and coherent approach to health governance is necessary to achieve sustained improvements in Nepal’s health system. While there has been much progress in the development of policies and subsequent guidance and procedures, gaps remain. These include: a lack of clear provincial and district roles within the health system; poor vertical and horizontal coordination and communication; inefficient systems to implement planned programs; and nascent emergency response systems. .

The growing private health sector provides ample opportunities to collaborate to expand access to quality health care. Recent national surveys show increased use of the private sector for health care services by all subgroups across the country. However, poor quality of services in the private sector is also rampant. For example, Nepal Health Facility Survey 2021 showed that only 12.3% of private hospitals assessed had appropriate storage of health care waste. The advancement of UHC coverage requires capacity building and participation of stakeholders from private health service outlets, pharmacies, and academic institutions. Ensuring that private actors provide quality MNCH and FP services in compliance with national standards; that they can easily understand, and adhere to, Nepal’s licensing and accreditation requirements; and that they report service data into HMIS are critical areas that require strengthening. Creating an enabling environment for the private sector to complement and to collaborate with the public sector would allow expansion of quality MNCH and FP services, especially in remote areas of the country, to achieve the UHC and SDGs envisioned by the GON.

Intermediate results towards achieving this objective are:

IR 1.1 Policies and guidelines are strategically formulated and implemented across three tiers of government.

The formulation and implementation of evidence-based policies is crucial for decision making and proper functioning of the health system. While the MOHP plays a central role in the development of policies,stronger leadership and capacity is needed at the provincial and municipal levels of government to ensure that these policies are adapted with their specific contexts and are effectively implemented at the provincial and local levels.The contractor must provide technical support to all three tiers of government to develop/adapt context specific health policies and strategies, to effectively implement them, and to measure the outcomes. In addition, the contractor must support the federal and provincial governments to better define and strengthen the role of health offices in the districts.The contractor must also help the GON develop and implement strategic plans for human resources for health.

To build good governance at all levels, the contractor must build capacities across the three tiers of government to ensure that policies and associated guidance are effectively implemented. Where policies are not being effectively implemented, the contractor must work with the appropriate GON counterparts to understand and address barriers, including support for planning, development of time bound goals, securing sufficient commitment of resources, and defining an effective accountability mechanism.

Effective policy development and implementation requires champions across government to help build knowledge, advocate for marginalized community needs, and help foster commitment to an equitable, quality health system. The contractor must continuously engage during planning and resource allocation, which is central to building ownership and effective policy implementation. The contractor must engage the private sector, and a range of critical stakeholders, throughout the planning-implementation-review cycle, which will contribute to the success of the NHS-SP envisioned by the GON. Regulation of and collaboration with the private sector will help to achieve the shared objectives of UHC and emergency preparedness. Public-private partnerships can open new opportunities to reduce the inequity in health care and to address the human resource gaps which persist in the public health care system.

At a minimum, the contractor must:

● Support the development, updating, and implementation of health sector policies, strategies, and guidelines for the three tiers of government, to increase access to, and use of, quality health care services, especially by marginalized communities.

● Support the MOHP and subnational level governments to develop/adapt policies, implement strategies and adapt systems to strengthen partnerships with the private sector including with academia and professional bodies.

● Support the MOHP and subnational governments to develop HRH strategies.

IR 1.2 All levels of government effectively coordinate and collaborate to deliver quality health services.

The transition to federalism and the devolution of authority throughout Nepal’s health system continues to create challenges related to the clear definition and understanding of roles, responsibilities, and requirements across the three tiers of the government. While these difficulties can impede implementation, they also provide the contractor with an opportunity to establish or improve coordination platforms and mechanisms. Where various parties have overlapping, or conflicting responsibilities, the contractor must provide technical assistance to help clarify and redefine these roles as needed, strengthen ownership, and avoid lapses in implementation.The contractor must provide customized technical assistance to three tiers of government to create opportunities to build their capacity to plan, prioritize, and customize health delivery at the local level and help to identify, prioritize, and implement key high-impact, sustainable approaches focused on quality MNCH and FP services. The continued presence of health offices in the districts, unlike in other sectors where similar structures were dissolved, provides an opportunity for the contractor to improve coordination between the local and provincial governments, to provide much-needed data analysis, and to potentially establish technical assistance hubs at those levels.

Given the substantial need to respond to complex health issues with a multi-sectoral approach, it is imperative that the GON coordinates across divisions and departments and across multiple health and social ministries utilizing existing data and pooling resources to reach and support the most marginalized with high quality services. The contractor must support effective coordination and collaboration across the three tiers of government to build and institutionalize responsive systems to deliver quality services.

The contractor must explore available platforms and regular opportunities to provide feedback. The contractor must also network provincial, district, and local governments to allow for greater knowledge exchange, to share successful models of health care delivery, and to promote evidence-based priority setting and resource allocation.

The contractor must establish regular communication to ensure clear, real-time coordination between relevant parties. Achieving this may require expanding existing communication platforms or establishing new platforms. The contractor must work to maintain effective collaboration ensuring regular follow-up and incorporation of learning. The contractor must provide capacity strengthening, resources, and assistance to local governments to properly participate in coordination and collaboration.

At a minimum, the contractor must:

● Provide technical support to establish or strengthen platforms and mechanisms to increase coordination and collaboration across the three tiers of government.

● Provide technical assistance to enhance the role of district health offices in improving the access and quality of care in both the public and private sectors.

● Provide platforms for three tiers of government to discuss and collaborate during annual work plan development and budgeting processes, review meeting minutes and annual performance reviews.

● Support provincial and local governments to develop systems that provide quality basic health services, especially MNCH and FP, even during emergencies as mandated by the Constitution, and to monitor and evaluate implementation and outcomes.

IR 1.3 Provincial and local governments effectively plan, budget, and deliver population responsive health services.

Local governments are responsible to provide basic healthcare services (mandated by the constitution) and to ensure that the services are responsive to community needs. This requires local governments to manage multiple resource streams, plan context specific health activities, determine cost-sharing, and develop annual work plans and budgets, among other duties. The contractor must provide technical support to local governments to complete these tasks to increase access to and quality of basic health care services, while weighing competing demands from citizens and other sectors. In addition, some local leaders have limited experience in managing health systems, and municipal health managers are less likely to possess the skills and capacity to plan and budget for basic health care to meet the needs of the community, especially the marginalized. These are among the key factors that lead to varied health outcomes across the population. The contractor must work to build capacity systematically, considering the local context and employ systems strategies to sustain capacity strengthening over the long term.

The SSBH final evaluation7 also identified that lack of training, limited participation from local representatives and municipal stakeholders, and inadequate budget allocation (including delayed disbursements) were some of the system level challenges that persist. The contractor must build on the achievements and learning from SSBH in this regard and address them creatively during the local governments’ annual planning and budgeting process.

As local solutions are developed, it may be determined that local leaders and health care managers require institutional support for planning and budgeting to provide quality basic health services accessible to marginalized populations. Planning and budgeting require that leaders and management staff become informed consumers of data, and that they demand generation of relevant, actionable, health and financial data. The contractor must support data ecosystems where they are weak, to realize more consistent, timely, and complete data.

The contractor must also ensure that delivery of services at this level also focus on the mobilization of resources and full budget utilization, ensuring that resources (including trained human resources) are available as needed, and community networks, such as those led by female community health volunteers (FCHVs), are strengthened and expanded. The HFOMCs supervise and manage facilities and play a critical role linking local governments and communities to the delivery of quality services. The contractor must strengthen ongoing and innovative HFOMC capacity strengthening efforts to achieve this IR.

Achieving this result will also necessitate provincial level capacity strengthening, ensuring there is continuity in health service implementation and sustainable systems to support quality service delivery.

This IR will benefit from and complement efforts under IR 1.1 around improved roles and responsibilities.

Determining who should lead, resource, and support critical functions, such as health worker training, may also highlight the need for new resources or capacity strengthening at different levels. Just as local governments and HFOMCs require capacity to listen to and incorporate citizen feedback, so too the provincial level needs to ensure proper feedback mechanisms are in place to respond to needs raised by local governments. Therefore, the contractor must work with provincial governments and district health offices to innovatively develop platforms and mechanisms and strengthen their capacity to effectively plan, budget, and deliver population responsive health services.

In the federal government systems, municipalities and provincial health directorates play an important role in ensuring equity in health care provision. The contractor must work to strengthen their capacity to use data for annual planning and budgeting, to improve logistic management systems for the last mile delivery, and to target marginalized communities with focused interventions to increase their access to health care, to ensure population responsive health services are available at the local level.

7 Final Evaluation of the Strengthening Systems for Better Health (SSBH) Activity, October 2023 https://pdf.usaid.gov/pdf_docs/PA021F7R.pdf

At a minimum the contractor must:

● Provide targeted technical assistance to local and provincial governments to advance planning, budgeting, delivery of health services, particularly MNCH and FP, and to improve the quality of care, including through improved water, sanitation, and hygiene interventions.

● Capacity strengthening of municipal and provincial government managers on planning, data use and resource allocation to provide quality health care especially to marginalized populations.

● Strengthen the capacity of HFOMCs and provide technical assistance during the annual planning and budgeting process.

IR 1.4 Direct U.S. government health assistance to the GON is operationalized.

The contractor must provide targeted technical assistance to maximize USAID G2G investments to promote health equity and quality health systems for the most marginalized. The contractor must respond to findings from USAID’s health G2G risk assessment and provide targeted technical assistance, which is critical to ensure USAID's direct health financing assistance is used effectively and responsibly.

This assistance must strengthen the capacity of leaders, health managers, financial managers, and reporting bodies in the three tiers of government to ensure efficient and rigorous financial management throughout the health system, not just for USG resources.

Improving financial accountability, ensuring safeguards are in place, and providing technical assistance to develop systems that eliminate waste, fraud and misuse are central to the success of the USG direct on-treasury, G2G, assistance. This IR will benefit from and complement efforts under IR 1.3 on supporting provincial and local governments to effectively plan, budget, and deliver population responsive health services.

The contractor must coordinate with the USAID Health Learning contract to conduct municipal health system capacity assessments. USAID Health Learning will conduct two rounds of these assessments - at the start and end of the activity; the contract may conduct similar assessments in other years. In addition to this survey data, the contractor is expected to use any other relevant assessment findings and recommendations that are available to develop technical assistance plans for the municipalities and to prioritize and schedule activities throughout the year.

At a minimum, the contractor must:

● Provide technical assistance to the three tiers of government to plan, budget and implement USAID’s direct health financing (G2G) support using data, to address local health needs.

● Provide technical assistance to address gaps identified under USAID’s G2G risk assessment and to implement USAID’s G2G risk mitigation plan.

Objective 2: Increased health system accountability and responsiveness to marginalized communities

Accountability and responsiveness in the health system requires communities, civil society, and other key stakeholders to be empowered and demand change. There are numerous barriers to optimal utilization of health services for communities, such as lack of health awareness, governance barriers, lack of trust, among others. Objective 2 will align with objectives 1 and 3 to reduce those barriers. Objective 2 aims to build health literacy, raise awareness, and empower communities, especially the marginalized and vulnerable, to access and demand quality MNCH and FP services. Finding creative solutions to overcome barriers, especially for those in the hardest to reach communities, will be achievable through IR2’s intermediate results.

Intermediate results towards achieving this objective are:

IR 2.1 Communities demand and utilize equitable and quality health services.

Demand for quality health services is created when individuals have accurate information and the agency to act on that information. To sustain demand and build trust, the health system must be responsive to the needs and preferences of the communities they serve. For example, considering the fact that home deliveries persist (19% as per NDHS 2022), efforts to increase awareness on service availability, break social barriers, and create a supportive environment to promote the use of health facilities, can facilitate equitable health care.

The contractor must support the GON to make health service information more available and encourage greater community participation with the health system. Information such as health services, working hours, and provider information, must be available at all health institutions. Patient rights, service costs, incentives, and compensation must be publicized in all facilities and communities. Mechanisms to provide feedback, including for improving access to and quality of services, need to be accessible and widely disseminated. The contractor must work with the GON in ensuring that data is regularly available in an accessible format which allows stakeholders, particularly those outside of the GON, to utilize data and provide invaluable feedback. This feedback will enhance policy implementation, contribute to health priorities, and promote the delivery of quality services. The contractor must increase public awareness and understanding around health indicators and facility data, including those related to quality and equitable distribution of health services. The USAID Health Learning contract will conduct Annual Client

Surveys, which will provide information on marginalized community needs, priorities, and service utilization to help strengthen these efforts. The contractor must utilize data from these surveys during the development of annual work plans.

To be responsive to community health needs, the contractor’s efforts must focus on expanding access to quality MNCH and FP services, including through outreach and innovative approaches, particularly for marginalized and vulnerable groups. The contractor must support relevant stakeholders in both public and private sectors, to strengthen referrals and to provide pathways for patients to receive high quality care that is responsive to their needs.

The contractor must develop mechanisms for regular, independent and/or self-assessments of facilities and services. These assessments must evaluate performance, and identify and monitor if facilities are adhering to national and global standards and providing high quality care. The assessments must be complemented by user surveys, allowing stakeholders to triangulate the findings both from service providers’ and recipients’ perspectives. This data must be widely disseminated in accessible formats to the public.

At a minimum, the contractor must:

● Support local governments to raise community awareness and increase demand and use of equitable and quality MNCH and FP services.

● Support innovative and context specific approaches to engage communities in health care planning, budgeting, delivery and monitoring.

● Develop and promote health budget literacy and assist the GON at all levels to promote appropriate fiscal allocation and optimal execution of the health budget.

● Foster opportunities for engagement with marginalized communities, civil society groups, and community leaders (especially those from marginalized groups) with HFOMCs and relevant decision making bodies during the annual planning and budgeting process.

IR 2.2 Stakeholder feedback and engagement mechanisms are institutionalized.

Institutionalization of stakeholder engagement mechanisms requires that platforms are established where they do not exist and be strengthened where they do. Platforms that allow for feedback include patient and facility surveys, community meetings, public consultations, complaint boxes/lines, among other types of engagement. The contractor must support the GON, program managers, HFOMCs, service providers and other stakeholders to establish effective platforms to help unite and organize stakeholder engagement in a way that allows local voices to become amplified and heard. Because of this, and to ensure services are delivered equitably to populations, it is important that equity and inclusion be foundational to any engagement mechanism.

The contractor must support the local, provincial, and federal governments to share responsibility to enable information and feedback platforms. Private sector, academia, professional bodies, associations, and non-traditional partners are also integral to institutionalizing effective health system feedback engagement mechanisms to bolster, quality equitable health care services. The contractor must ensure regular and open communication, directly with marginalized communities, which will strengthen channels of communication and ensure institutionalization of these mechanisms. Enabling channels of communication also means ensuring that all these channels are functional and responsive to population needs. While the use of social media and properly functioning online communication applications are critical for some citizens, feedback from others might better be obtained through radio programs, listening sessions, and community meetings. The contractor must innovate and adapt to the local context and need. The contractor must support the GON to set up or strengthen existing feedback mechanisms that must communicate the actions taken, to those who provided feedback, thus ensuring a complete feedback loop.

Depending on the context and situation, various local NGOs, civil society leaders, and health workers will serve as intermediaries between providers and the public, providing collective community feedback. The contractor must strengthen the capacity of these groups and support them to organize and communicate, which will contribute to successes under IR 2.2, especially considering that the voices of many disadvantaged groups may not be easily heard. Communities, academia, and the private sector may benefit from greater engagement with each other. Where capacities are low, the contractor must support capacity development and empowerment efforts to build sustainable capacity for advocacy and engagement and to use information to contribute to systems level improvements.

At a minimum, the contractor must:

● Support institutionalizing rigorous stakeholder and participant closed-loop feedback mechanisms which foster accountability and transparency, including service delivery assessments and surveys.

● Where needed, support the development of new platforms for strengthening communication across stakeholder groups.

● Support the GON to build and strengthen partnerships and improve the enabling environment with professional bodies, private sector, academia, and non-traditional partners, to improve access and utilization of quality MNCH and FP health services, especially for those who are left behind such as those living in remote and rural communities, and in poor urban areas including urban slums.

● Analyze and strategically support system accountability functions, ensuring that financial, policy, governance and service delivery accountability is upheld.

● Where needed, support the development of new platforms for strengthening communication across stakeholder groups.

Objective 3: Improve targeted health service quality for marginalized groups .

A comprehensive approach is needed to provide accessible, quality services to marginalized groups.

Systematic challenges such as: gender norms, diverse languages, poverty, social exclusion, stigma and discrimination, low educational attainment, and geographic access can contribute to poorer health outcomes, disproportionately affecting the most marginalized. Furthermore, a lack of awareness and information, social norms and cultural practices, and poor-quality services, including discrimination and provider bias, also limit equitable access to and utilization of health services. Service providers, health managers, policy makers, and GON counterparts at all levels need to be aware of the specific barriers to health care in various contexts, so that they can develop responsive, quality service delivery, especially on MNCH and FP.

Intermediate results towards achieving this objective are:

IR 3.1 Providers and managers have the capacity…