RFI_720656-2024-SUCESSO English and Portuguese signed.pdf

SOLICITATION TYPE: REQUEST FOR INFORMATION (RFI)

RFI NUMBER: RFI- 720656-2024- SUCESSO

PROGRAM NAME: SUstaining Control the HIV Epidemic through quality

Services, resilient Systems, and Community Outreach

(SUCESSO)

ISSUANCE DATE: June 11, 2024

CLOSING DATE: August 12, 2024; 17:00 (Maputo Time)

TO: ALL INTERESTED PARTIES

Dear Potential Applicant/Offeror, USAID/Mozambique intends to design a new HIV Activity - SUstaining Control the HIV Epidemic through quality Services, resilient Systems, and Community Outreach (SUCESSO) - that will support and contribute to the Government of the Republic of Mozambique (GRM) to reach and sustain HIV epidemic control in four provinces - Sofala, Manica, Tete and Niassa. This is anticipated to be a five (5) year award(s) - 2026 - 2031, with a total value of up to $155 million.

The purpose of this communication is to obtain industry comment and input on the above-mentioned program. More specifically, the RFI intends to:

○ Assess the interest of potential organizations in submitting applications/proposals for the new Activity - SUCESSO.

○ Gain technical and organizational insights in the capacity of potential organizations.

○ Explore innovative approaches to partnering with organizations working in the same area; and

○ Collect inputs to contribute to the improvement of the proposed Program Description (PD)/Statement of Work (SOW).

Attachment II presents the set of questions to which organizations should respond. Note that this is a RFI and not a Request for Applications (RFA) or a Request for Proposals (RFP). This RFI is not to be construed as a commitment by the U.S. Government to issue any solicitation or ultimately an award on the basis of this RFI, or to pay for any information submitted as a result of this request. It should be noted that responding to this RFI will not give any advantage to any organization in the subsequent procurement.

USAID/Mozambique may use feedback and comments from this RFI to develop future programs.

If a solicitation is issued for this activity, it is the organization’s responsibility to monitor the sites https://www.grants.gov or www.sam.gov and local newspapers for the release of any further information.

https://www.grants.gov/n http://www.sam.gov/

Please submit responses to this RFI to the Agreement/Contracting Officer, Patrice Lopez at mission-maputo-oaa@usaid.gov no later than the closing date provided above. Late submissions will not be accepted. The subject line of the e-mail must read “RFI – USAID/Mozambique HIV Epidemic Control Activity (2026 - 2031)”. Responses must include the organization's name, address, point of contact, phone number and email address. You will receive an electronic confirmation acknowledging receipt of your response. Hard copy responses are not required and are discouraged.

Best regards, Ayla-Rebeka Brooks Supervisory Contracting and Agreement Officer

Attachments:

ATTACHMENT I –DRAFT PROGRAM DESCRIPTION/SCOPE OF WORK

mailto:mission-maputo-oaa@usaid.gov

ATTACHMENT I –DRAFT PROGRAM DESCRIPTION/SCOPE OF WORK

A. INTRODUCTION

The main goal of the SUstaining Control the HIV Epidemic through quality Services, resilient Systems, and community Outreach (SUCESSO) is to support a sustained national HIV response to reach and/or maintain HIV epidemic control by 2031 in select provinces supported by USAID clinical programming, namely: Sofala, Manica, Tete and Niassa, while transitioning up to 90% of HIV services portfolio to Provincial Health Services (SPS/Provincial Health Directorates (DPS).

The period of performance is five years, and the total estimated amount to be awarded is US$155,000,000 million.

Aligned with the PEPFAR's Five-year Strategy (December 2022), the PEPFAR Sustainability Roadmap, the recently presented HIV National Acceleration Plan (2024 - 2026), and the National Plan for the Triple Elimination of HIV Vertical Transmission, Syphilis and Hepatitis B in Mozambique (2020-2024), this activity responds to USAID Mozambique Country Strategy Development Objective 1: Healthier and Better Educated Mozambicans, especially the young and vulnerable, and aligns with USAID's global strategy on localization, which seeks to enhance the engagement of local partners by aiming to achieve a 50% involvement of local partners by 2030. Accordingly, SUCESSO will leverage localization lessons learned and experience of USAID/Mozambique's Integrated Health Office (IHO) and is expected to build on the gains and results of enhanced provincial-level capacity building being provided by USAID current HIV Program, “Efficiencies for Clinical HIV Outcomes” (ECHO) project, implemented by Abt Associates, and, capitalize on the current USAID Government-to-Government Agreements (G2G) investments across the same provinces.

SUCESSO will aim at achieving the following results by 2031:

● Result 1 (R1): Improved performance and Quality of HIV Services

● Result 2 (R2): : Increased resiliency of provincial health systems to support HIV response

● Result 3 (R3): R3: Strengthened high quality, comprehensive community-based HIV prevention and treatment services.

SUCESSO is expected to support government efforts on that extra mile to ensure that gaps are addressed and that the country is on the right path to achieve and maintain 95 95 95 in these 4 provinces, using a provincially differentiated implementation approaches and support packages that consider epidemiologic and demographic profile, progress towards HIV epidemic control, and identification of locally specific gaps.

B. PROGRAM DESCRIPTION/SCOPE OF WORK

B.1 Background and Problem Analysis Mozambique is a country of more than 34.5 million people, with a median age of 17.0 years.1 The total fertility rate is 4.6 and life expectancy at birth is 59 years.2 The country is challenged by high levels of poverty, with 42.1% of the population without access to drinkable water, 14.7% without access to electricity, and 71.3% without access to sanitation.3 Mozambique continues to rank low in the United Nations Human Development Index, ranking 185 out of 191 countries.4

Shortly after obtaining independence in 1975, Mozambique entered sixteen years of civil war that highly impacted the country's overall infrastructure. Over the past half-decade, Mozambique has weathered a series of significant challenges, including major health crises (e.g., COVID-19, cholera, and wild polio) and escalating frequency and severity of climate-related disasters. Cyclones Idai (2019), Kenneth (2019), Freddy (2023), and Filipo (2024) have not only disrupted livelihoods but also wrought havoc upon infrastructure and exacerbated the displacement of communities. Among the adult population (15 - 59 years old), HIV was the lead cause of death (25%) followed by infections, such as meningitis/encephalitis (22%) 5. Despite these harrowing statistics, between 2009 to 2019, the country has seen progress in key health indicators, including a 50% drop in mortality due to malaria, and a 28% reduction in mortality due to diarrheal diseases and lower respiratory infections.6 The most recent Demographic Health Survey also shows that under-five child mortality has declined from 97/1,000 in 2011 to 60/1,000 in 2022/23, and that institutional labors have increased from 55% to 65%.7

HIV prevalence among adults in Mozambique is 12.5%, with current models estimates 2,4 million adults living with HIV8, with prevalence higher among women (15.0%) than men (9.5%).

The country has taken major strides forward in the past several years with 71.6% of adults (15+ years old) being aware of their status, 96.4% were on antiretroviral therapy (ART), and 89.4% were virally suppressed. Individual sub-populations, like pediatrics, adolescents, and young men, lag behind the general population.9 https://www.worldometers.info/world-population/mozambique-population/

UNFPA. Dinâmicas da População de Moçambique. Censo 2017.

Available:https://drive.google.com/drive/folders/1wsDxbtlkRYP1TKhwAR82v8vRdgc_vQWl https://databank.worldbank.org/views/reports/reportwidget.aspx?Report_Name=CountryProfile&Id=b450fd57&tbar=y&dd=y&inf=n& zm=n&country=MOZ 3 World Bank. Poverty & Equity Brief. Mozambique. April 2023 UNDP. Human Development Report. 2021/2022. Available: file:///C:/Users/mbranquinho/Documents/hdr2021-

22reportenglish_0%20(1).pdf https://www.ajtmh.org/view/journals/tpmd/108/5_Suppl/article-p5.xml

Institute for Health Metrics and Evaluation. Mozambique. Available: https://www.healthdata.org/research-analysis/health-by-location/profiles/mozambique 7 Instituto Nacional de Estatística (INE). Inquérito Demográfico e de Saúde. 2022-2023 https://drive.google.com/drive/folders/1wsDxbtlkRYP1TKhwAR82v8vRdgc_vQWl

INS. MOZAMBIQUE POPULATION-BASED HIV IMPACT ASSESSMENT (INSIDA). 2021

https://www.healthdata.org/research-analysis/health-by-location/profiles/mozambique https://www.healthdata.org/research-analysis/health-by-location/profiles/mozambique

B.2 Overall Geographic Focus SUCESSO will be implemented in Sofala, Manica, Tete and Niassa Provinces, with the possibility to expand to other provinces based on emerging needs identified by the USAID Mission, Integrated Health Office and/or PEPFAR inter-agency team. In 2019, PEPFAR agreed with the Ministry of Health to support a subset of all public health facilities providing HIV services through its implementing partners. These sites, affectionately known as AJUDA sites, serve 85% of all ART clients across the country, although ART client coverage may differ across provinces.

While these sites have not shifted much over the past five years, as implementation evolves and new epidemiologic data become available, adjustments may be required, as dictated by USAID. Synergies and complementarity with non-AJUDA sites, which are supported by provincial authorities with PEPFAR and non-PEPFAR funds, are encouraged to maximize the likelihood of reaching and/or maintaining provincial HIV epidemic control.

B.3. Logical Model and Intended Results Current USAID-supported HIV service scale-up to an environment in 2031, where the majority of the HIV response is locally-led, sustains high levels of HIV treatment coverage and viral suppression, complemented by prevention interventions to reduce HIV transmission (Result 1 and Result 3), and buttressed by stronger provincial health systems (Result 2). USAID is committed to shift more leadership for priority setting, project design, implementation, and measuring results to the people and institutions with the capabilities and credibility to drive change in their own countries and communities. SUCCESSO will require a nuanced package of support, tailored to the local context, which may vary not only by province, but also across different communities within provinces. Having a strong understanding of strengths and challenges in these local communities will allow the awardee to tailor the support according to local needs as needs continue to change over time. SUCCESSO activities will be predicated on a regular review of provincial and local program data, determination of gaps, engagement of target populations in both program design and implementation, and subsequent programming and assessment of interventions that address those particular identified gaps.

Result 1: Improved Performance and Quality of HIV Services Strengthening HIV program quality and fostering service quality improvement is core to achieving 95-95-95 goals, improving the health of the Mozambican people, and providing client-centered appropriate prevention interventions to at-risk individuals. As provinces get closer to epidemic control, closing those final gaps will likely involve innovative approaches, tailored support to different subsets of PLHIV, and keen awareness of how to provide high quality care in a cost-effective manner. The quality and reach of HIV services in Mozambique has made strong strides in recent years,but still, there remain gaps and inequities in the response.

Population-level viral suppression remains lower in areas of the middle and north of the country (particularly Sofala), when compared to the south, and rates of viral load suppression remain stubbornly low among adolescents and young adults. Improving the quality and patient-friendliness of services will help close those gaps and set Mozambique on the path to epidemic control. Streamlining and simplifying services, bringing them closer to clients and reducing the need for multiple facility touch-points, will further enable PLHIV to remain healthy and engaged in HIV treatment. Targeted integration across disease areas may also allow for de-stigmatization of HIV and greater uptake of HIV prevention services among individuals who might be at risk of HIV acquisition.

IR 1.1: Strong Combination Prevention iInterventions

Some Illustrative activities:

● Integrate prevention services (HIV Testing, PrEP Provision, condoms, referrals to VMMC) into primary healthcare, Family Planning, and ANC/MCH services.

● Integrate sustainable, low- cost technology solutions to support and connect prevention services and clients (e.gx., tele-medicine), and/or support clients receiving on-going prevention services, such as PrEP.

● Provide PrEP through differentiated service delivery models (facility and community-based) and through multi-month dispensing. Align DSD models with other prevention and & health promotion activities (such as family planning services provided in the community).

● Utilize up-to-date and local data to target services towards key gaps and populations, de-prioritize where there is saturation; improve collection and use of holistic prevention data and outcomes.

● Increase community participation in health decision- making forums and working groups.

● Develop and execute private sector engagement plans/solutions (e.gx., PrEP from private pharmacies ory, health insurance to provide coverage for prevention services).

● Create SOPs and implementation models for new PrEP modalities that expand choice (long-acting injectables, co-formulated OCP/PrEP tablets, vaginal rings, etc) as allowed under Mozambican guidelines. Support the evaluation, piloting and adoption of new products as they become available.

IR1.2: Robust HIV cCase iIdentification iInterventions

Some Illustrative activities:

● Leverage a mixture of PITC, HIV self-testing, and voluntary partner notification (index testing) tailored to the local context.

● Perform data reviews to examine where HIV testing is being offered and where HIV-positive individuals are either (a) being newly diagnosed, or (b) re-entering care.

● Monitor ongoing monthly outcomes to inform approaches (e.g., if high positivity in age-sex bands, increasing coverage); identify low volume-low positivity sites or high volume-low positivity sites for targeted changes or quality improvement activities.

● Leverageing machine-based learning models utilizing, based on program data, such as virologic non-suppression, interruptions in treatment and gaps in prevention interventions, to predict where HTS services are likely to help identify PLHIV in need of treatment.

● Integrate “status neutral testing” at service delivery points likely to be utilized by populations where the HIV knowledge gap remains large.

● Offer of voluntary index and partner testing, including assisted and unassisted partner notification and contact tracing services (which adhere to WHO rights-based minimum standards of informed consent, confidentiality, counseling, correct test results, and connection to treatment or other services).

● Provision of multiple options for delivering index partner testing for different client preferences, including anonymous methods for PLHIV not ready or willing to disclose.

IR 1.3: Effective HIV Care & Treatment Continuity Activities

● Provide facility-based HIV treatment services that ensure continuity of treatment for all population segments irrespective of duration on ART through innovative people-centered service delivery models and use of digital health technology.

● Assess potential barriers to continued adherence and retention for all clients on a regular schedule, assessing the desire for services through differentiated service delivery (DSD) models

● Offer ART through decentralized drug distribution (DDD) models where available, including, but not limited to multi-month dispensing (MMD), mobile brigades, community ART Groups (CAGs), private sector pharmacies, family clinics, mobile outreach clinics, and community/APSS ART distribution.

● Collaborate with relevant stakeholders to align and bundle other essential medicines (or associated relevant commodities) with multi-month dispensing and decentralized drug delivery activities, thereby increasing return on investment for current existing systems put in place originally just for HIV medications.

IR 1.4: Improved Viral Load Testing Coverage and Sustained VL Suppression

Illustrative activities (in addition to IR1.3 Illustrative Activities):

● Saturate viral load coverage and sustain viral suppression rates through targeted demand creation in all DSD models.

● In collaboration with provincial and district health departments, leverage multi-functional point of care testing for EID, TB, HPV and/or Viral Load where it improves quality and/or efficiency over standard sample transport systems.

● Routinely document sample collection, relevant client data, and result return times.

Collaborate with partners providing laboratory sample transport to analyze data and improve the timeliness of result return.

● Leverage digital technology to provide results to clients in near-real time, where feasible, and in alignment with principles of privacy and confidentiality.

● Strengthen management of treatment failure at all levels of care, which includes, but is not limited to, capacity building of service providers on enhanced adherence counseling;

U=U treatment literacy, optimal viral load coverage, and active clinical case management of viremic patients and those confirmed to have treatment failure.

Result 2: Increased resiliency of provincial health systems to support HIV response

As Mozambique progresses toward HIV epidemic control, the management of HIV as a chronic condition will require a health system that is resilient; well-financed and managed; and efficiently resourced (e.g., human resources, equipment, commodities). The COVID-19 pandemic highlighted the importance of resiliency of local health systems to withstand unanticipated shocks. In addition to COVID-19, Mozambique also suffers from security concerns in areas of the north, and has endured multiple environmental shocks, further highlighting the importance of strengthening the resilience of local health systems to serve people living with HIV. Building this resiliency will encompass several different elements, including the management and oversight of health facilities (and community-based programs); strategic deployment of available resources; use of data to inform planning and make necessary adaptations; and the creativity to pivot programming in the setting of unanticipated shocks.

Alongside the objectives described in Result 1, SUCCESSO will simultaneously work with provincial (and district) governments to improve the use of data for decision-making purposes, strengthen laboratory and pharmacy capacity, and optimize the deployment and skillsets of human resources in the supported regions. The specific blend of programmatic and systems strengthening work will need to be tailored to the needs of specific provinces.

IR 2.1: Systematic use of data for decision-making purposes

Some Illustrative activities:

● Facilitate and model regular data review meetings with provincial leadership and/or health management teams, focused on identifying specific changes to improve the overall quality of service delivery.

● Strengthen capacity of health care workers to use data at the facility level (e.g. through trainings, mentoring, or quality improvement collaboratives) to drive improvements.

● Ensure interoperability between health information systems across disease areas to facilitate integrated programming for clients, and the availability of holistic data reports at the provincial level.

● Work jointly with community-level monitoring (CLM) stakeholders and provincial/district managers to analyze data, design strategies for improvement, and improve the transparency of quality improvement efforts.

● Strengthen capacity to ensure data quality and reliability, through standardizing data quality assessment (DQA) approaches, supporting DQA processes and instituting appropriate changes to improve the accuracy of data collected.

IR 2.2: Appropriate laboratory and pharmacy capacity to address evolving program needs.

● Support the implementation of electronic laboratory and logistics information systems at the facility level, including roll-out, HCW training, and maintenance (where appropriate).

● Develop SOPs in tandem with provincial/district leaders to ensure communication of stock-levels (pharmaceuticals, supplies and laboratory reagents), redistribution of commodities (as required), ordering and reporting, between facilities and local/regional warehouses.

● Support necessary policy changes and coordination of provincial governance structures (and potential realignment) to ensure integration of HIV and other health services that can be cascaded to the lowest-tier health facilities, community systems and structures

● Support integration of forecasting, supply planning, supply chain logistics, and stock management of health commodities beyond those for HIV, to include other essential medications and diagnostics (i.e., HTN and DM medications and supplies) for NCDs, family planning, COVID, sexually transmitted infections, VMMC, post-GBV care, and other community programming and PHC needs.

● Support integrated laboratory diagnostic work (including mapping and optimization exercises) on common platforms across disease states, including health threats (e.g., TB, HPV, HIV/EID, COVID)

IR 2.3: Strategic use of facility-based human resources and implementation of community-sub system

Some Illustrative activities:

● Technical support to the provincial management teams in policy formulation, operationalization, and coordination with district health management teams (DHMTs) on sub-national dissemination of HIV, and other related health policies, guidelines, M&E tools, and training materials.

● Provide technical assistance to improve HRH management within provinces, including reducing vacancy rates, optimizing deployment of new HRH, and ensuring clearly outlined communication between facility and community-level HCWs

● Develop provincial level HRH strategies, including staffing plans, developed and approved in line with GoM and provincial guidelines.

● Upskill the PEPFAR-supported health workforce to provide other PHC services (e.g., MNCH, SRH, TB, FP, COVID, NCD, MH, GBV, and community care & support) for PLHIV as a bridge towards a multidisciplinary health workforce that can provide comprehensive and integrated services.

● Align the PEPFAR-supported health workforce (both facility-based and community-based) with the local health workforce structure in collaboration with relevant line ministries (e.g. finance and planning).

Result 3: Strengthened high quality, comprehensive community-based HIV prevention and treatment services.

Community engagement is a critical component of high-quality primary healthcare for people living with HIV. Provision of basic services for both prevention and treatment through community platforms helps reduce the costs for PLHIV to access ongoing care, opens up new avenues for HIV prevention, and helps reduce the stigma associated with HIV. Coordination of integrated community-facility programming that is incorporated into governance structures ensures comprehensive, locally led health services that can be delivered as effectively and potentially more efficiently than traditional care. Defining the package of services to be delivered through community-based actors (community HRH cadres, local organizations, etc), establishing guidelines for ongoing support and referrals, and ensuring effective referral systems between health facilities and community structures are three important elements that support community-based care.

IR 3.1: Robust behavioral and biomedical HIV prevention interventions to increase individual risk perception and promote positive community norms

Some Illustrative activities:

● Improve treatment literacy levels, including U=U messaging, among clients and in communities.

● Work with community and faith leaders to broaden messaging platforms and de-stigmatize HIV.

● Using feedback from community leaders, use locally relevant messaging platforms to increase understanding and awareness of PrEP and VMMC programs

● Increase the capacity of public systems to include the monitoring and evaluation of SBC interventions, including randomized impact evaluations and evaluations of cost-effectiveness, as a core component of any integrated public health program

● Integrate HIV services into the local community structures for general health promotion, prevention, and detection and intentionally integrate HIV services with relevant programming platforms for other line ministries outside health such as social welfare, education, youth and women's affairs, and finance.

IR 3.2: Extensive community outreach to PLHIV to provide holistic care and support

● Strengthen community health systems to integrate HIV into existing community health services, reduce interruption in treatment and support re-engagement in to care, including, but not limited to, appointment reminders, active tracking systems, targeted clinical case management, non-judgmental, supportive providers, and virtual adherence support, and innovations for re-engaging highly mobile populations in care. Sensitivities to the varied needs of the populations served (e.g., young adults, adolescents, KPs, men, families) should be a focus of mentoring of all providers to address beneficiary reticence in engagement in services.

● Assess the knowledge, skills, and support needs (including commodities) for community-based health workers to provide a comprehensive suite of integrated health services, including for HIV, and develop interventions to address the identified needs. Train and support community health workers to provide the core package of health services as necessary.

● Integrate HIV services into the local community structures for general health promotion, prevention, and detection and also intentionally integrate HIV services with relevant programming platforms for other line ministries outside health such as social welfare, education, youth and women affairs, and finance.

● Work with provincial leaders to create formal SOPs for community health workers and standardize oversight and coordination with ‘parent’ facilities. Support CHWs with the appropriate digital and paper tools to document service provision and receive decision-making support from facility-based health workers when required.

● Ensure coordination and referrals between clinical and community-based support services for children and families to support adherence, including case conferencing.

B.4. Implementation Approach

SUCESSO represents a pivotal interim step in supporting USAID’s vision of gradually transitioning up to 90% of clinical cascade service delivery activities to G2G agreements by 2031. The project’s ability to support provincial capacity for a sustained and efficient national HIV response is fundamental to its success. USAID is seeking a continuation of effective interventions coupled with innovative tactics to reach and serve specific subpopulations lagging behind. At the same time, USAID is promoting the use of provincially differentiated implementation approaches and support packages that consider epidemiologic and demographic profile, progress towards HIV epidemic control, and identification of locally-specific gaps.

In April 2026, SPS/DPSs will each be at different stages of capacity to directly manage the HIV service delivery portfolio. As such, the type of support required by the applicant/offeror will differ by province. The Activity is expected to assess the provincial context at the time of project initiation to ensure interventions are tailored to the unique context of each province. SUCESSO has the benefit of capitalizing on both the gains of enhanced provincial-level capacity building efforts currently being provided by the USAID-supported Efficiencies for Clinical HIV Outcomes (ECHO) project, implemented by Abt Associates, as well as existing USAID investments under G2G agreements in each province. Through a collaborative decision-making process with USAID and SPS/DPSs, annual consensus should be reached on the most suitable and effective approach --be it direct service delivery, technical assistance, or a combination of both -- acknowledging that the model will shift as the Activity ages.

[SOFALA and NIASSA] SUCESSO will focus on strengthening the capacity of the Mozambican public health sector, upon which all HIV services rely, to achieve and maintain epidemic control.

Despite significant progress in closing HIV clinical cascade gaps, an initial direct service delivery approach is anticipated. This includes intensive support at the facility- and community-levels for the delivery of HIV prevention, care, and treatment services to maximize the number of HIV-positive clients on treatment, ensure adherence and retention, and prevent new infections. In addition, support for facility-based human resources and community-based support staff are anticipated. The expectation is these interventions will be implemented through an institutional strengthening approach, resulting in less direct service delivery and more technical assistance over the years.

[MANICA] Based on significant progress in closing HIV clinical cascade gaps, a combination of some direct service delivery approaches and some more broad technical assistance is anticipated. Whereas routine supervision of HIV services and training of personnel may be adequately managed by provincial authorities, support for human resources, information systems and community interventions may require additional intensive support in the initial phase of the Activity. Assessing the provincial context at the time of project launch, as well as existing G2G activities, will shed critical light on where the Activity may be best suited to fill critical gaps. The annual work planning process will also be a critical moment to align efforts between this Activity and G2G efforts. While the priority is ensuring that clients receive quality, person-centered care, the expectation is that the SPS/DPS will have greater capacity to deliver on this priority throughout the life of the Activity.

[TETE] Based on significant progress in closing HIV clinical cascade gaps and a well-established Tete Province G2G agreement since 2019, the expectation is that HIV direct service delivery interventions will be channeled through the G2G, with SUCESSO offering technical assistance to ensure quality service provision as well as supporting complex program areas with additional expertise. While overall reporting, maintenance of reporting systems, and human resources, including direct service delivery staff, site-level lay staff and data clerks, and community-based cadres) will be under the Applicant/Offeror’s responsibilities at the onset of the project, gradual transition of these responsibilities throughout the life of the project is anticipated. The Applicant/Offeror is encouraged to present a creative and cost-effective approach to technical assistance, acknowledging the local context and areas of greatest need.

To meet transition objectives, the Applicant/Offeror must present a plan demonstrating its path for gradual transition, supported by capacity assessments. The plans should present a clearly articulated phased set of activities and functions, with concrete milestones, that will be transitioned over the life of the Activity. After project launch, joint annual reviews between SUCESSO, SPS/DPS, and USAID are expected to make consensus-oriented decisions on how and when to transition interventions. While the goal is to transition 90% of the HIV service delivery portfolio directly to G2G agreements by 2031, USAID acknowledges that the path may be circuitous. The Applicant/Offeror plays an essential role in anticipating and addressing potential setbacks and challenges throughout the process. The Applicant/Offeror is expected to be prepared to mitigate any backsliding and intervene promptly, ensuring uninterrupted service delivery and safeguarding of provincial clinical cascade achievements.

Whether implementing directly, providing technical assistance, or some combination of the two, SUCESSO is encouraged to consider:

● application of costing and cost-outcome analyses, or cost-effectiveness analyses for questions that indicate the benefit of certain interventions;

● rapid adoption and utilization of approaches, models, or best practices that are “quick-wins”;

● strong synergies with community entities and partners to share in the delivery of services and in the achievement of results; and

● readiness and early uptake of promising policy reforms and strategies, and early adoption of state-of-the-art practices.

The Activity will also work to ensure consistent utilization of the latest evidence and data for decision-making and rapid scale up of effective HIV interventions. In addition, the Activity will support and guide civil society in implementing a response that responds to their specific communities’ needs. Furthermore, SUCESSO is expected to propose and utilize models, approaches, and methods of service delivery based on gaps identified through: ongoing analyses of results achieved to date and HIV epidemiological context, epidemic drivers and challenges by province/region and population (i.e. children, youth, men and pregnant women) Government of Mozambique and PEPFAR priorities, PEPFAR Technical Considerations from the most recent annual country operational plan (COP), and any emerging new evidence.

SUCESSO’s has been developed based on the following assumptions:

● USAID/Mozambique’s Integrated Health Office views Government-to-Government agreements (G2Gs) as the long-term strategy to support a sustained HIV response in the country;

● USAID/Mozambique’s Integrated Health Office G2G mechanisms are consistently funded in a timely fashion to ensure no interruption in service provision;

● Provincial government capacity continues to positively evolve, with demonstrated capacity to assume greater service delivery responsibilities; and

● USAID/Mozambique’s Integrated Health Office will have stand-alone institutional capacity building mechanisms to support both provincial G2G mechanisms and civil society organizations, complementing the technical support being provided through

SUCESSO.

Should any of these assumptions change or not be met, adjustments to SUCESSO’s implementation model will likely be required. USAID will take the lead in signaling if it foresees any alterations required based on annual planning discussions, budget allocation, or any other strategic discussions. The Applicant/Offeror is also encouraged to highlight concerns or necessary adjustments in a timely fashion, offering proposed solutions that will most efficiently support quality, patient-centered services while maintaining a vision toward increasing SPS/DPS responsibility.

B.5. Management Approach/Key Personnel SUCESSO aims to establish a robust management and staffing framework that prioritizes a strong technical footprint at the provincial level, supplemented by a subset of advisors at the central level. These advisors will cover various technical domains, ensuring comprehensive engagement with the Ministry of Health (MoH), including participation in technical working groups, providing assistance, aiding in policy and strategy development, while providing technical assistance and ensuring alignment with national guidelines and standard operating procedures (SOPs) at the provincial level. At the central level, staff members will maintain regular communication with counterparts at USAID/Mozambique and MoH. USAID anticipates that SUCESSO proposes a structure that ensures timely and efficient intensive supportive supervision to all sites, with greater frequency for health facilities that are of greater volume and/or are struggling to meet expectations.

Additionally, SUCESSO plans to deploy up to three embedded advisors directly at MoH, pending confirmation and in accordance with USAID guidelines. These advisors are expected to receive support for necessary equipment and report on a daily basis to MoH.

Key Personnel

Key personnel are considered essential to the work being performed under this award. These are full time positions thus requiring 100% Level of Effort (LOE) allocated to the project. The following list of key personnel is proposed:

1. Chief of Party

2. Technical Director

3. Strategic Information Director/Lead

4. HSS Director/Lead

5. Financial Director

Before removing, replacing or diverting any of the listed Key Personnel, the Recipient/Contractor must:

1) request approval from the Agreement/Contracting Officer reasonably in advance; and

2) submit justification, including proposed substitutions with sufficient detail to permit evaluation of the impact on this contract.

Unless specified in writing by the Agreement/Contracting Officer, no replacement of Key Personnel shall be made by the Applicant/Offeror without the written approval of the Agreement/Contracting Officer.

B.6. Summary of Relevant USG and Donor Activities USAID/Mozambique’s Country Development Cooperation Strategy (CDCS) 2020-2025 guides all USAID programming to support the Mozambique health sector. SUCESSO falls under Development Objective (DO) 1: Healthier and Better Educated Mozambicans, especially the young and vulnerable, and supports the achievement of three intermediate results (IRs) under this DO 1: IR 1.1 Quality of Health and Education Services Improved; IR 1.2 Utilization of Health and Education Services Expanded, Focusing on Youth and Gender; and IR 1.3 Resilient Health and Education Systems Strengthened.

SUCESSO is central to the Mission’s PEPFAR portfolio and should be implemented in close coordination and through synergies with other USG and non-USG health and HIV investments.

Opportunities for complementarity can be found both at the central and provincial levels, offering numerous ways to amplify impact and extend reach across shared priority geographic areas. Acknowledging the multitude of challenges facing many of our beneficiaries, the most cost-efficient approach to offering holistic services and care that is so desperately needed to have long-term sustainable impact is through thoughtful and intentional partnerships and referrals. USAID/Mozambique’s Integrated Health Office has funding in a wide range of areas, from HIV-focused programming to maternal and child health, malaria, family planning, TB, global health security, and health systems strengthening. Global Fund has a significant HIV, TB, and malaria portfolio, in addition to an increased focus on health systems strengthening. There are many other active contributors in the health arena, including the World Bank and the broader United Nations family, that are pivotal to the national response to improve health outcomes. Of course, other technical offices within the Mission, including education, democracy and governance, economic growth, and environment, also have a crucial role to play in building resilience and the health and well-being of the Mozambican population. Identifying potential collaborative efforts to address the holistic needs of our beneficiaries is highly encouraged.

C. STRATEGIC CONSIDERATIONS

C.1. Gender Women are disproportionately affected by HIV; according to 2021 INSIDA data, prevalence of HIV among adults in Mozambique was 12.5%, with women being more infected (15.0%) than among men (9.5%), and HIV prevalence was two to three times as high among women as among men for youth between 15-29 years. Compounding this issue is the alarming rate of early sexual activity among young people aged 15 to 24, with 19% initiating sexual activity prematurely. This trend correlates with data from UNICEF, which highlights a concerning prevalence of child marriage, affecting 17% of girls under the age of 15 and a staggering 53% under the age of 18.

Moreover, early sexual initiation is three times more prevalent among young women with limited or no access to education compared to their counterparts with higher educational attainment levels. All interventions under this Activity must be designed using a gender lens and utilize gender transformative approaches at the individual, community, structural, social and political levels to achieve epidemic control.

USAID conducted a design-level gender analysis for this Activity and identified the following as opportunities in clinical HIV services: youth friendly services, safe space for key populations, improved empathy and privacy of providers, peer educators and leveraging of social media for young people, more accurate information on PrEP and HIV treatment, and improvement of GBV linkage and response. While the general issues around gender and inclusion for an effective HIV response are known, the successful Applicant/Offeror will be expected to conduct an Activity level Gender and Social Inclusion (GESI) Analysis and Action plan within 90 days of the award to ensure gender and social inclusion issues are addressed within the Activity. The implementing partner should focus on understanding how specific issues related to gender, youth, Persons with Disabilities and key populations affect their access to services and results for different groups, and identifying/refining differentiated strategies for ensuring no groups are left behind in the HIV response. This analysis should identify gaps and opportunities related to gender and youth that are specific to the areas of implementation. MER indicators should capture reach and results of different populations groups by age, gender and vulnerability status. The MEL plan should include strategies to monitor and respond to gendered differences in programmatic results, with review of data and corrective measures incorporated into management practices. To the extent possible, the partner should involve youth and key populations in MEL activities. Finally, quarterly reports should include updates on gender/youth challenges and corrective measures or strategies employed to reach vulnerable populations.

C.2. Youth Youth is a cross-cutting issue identified in the Mission’s CDCS and is considered a key focus group both for USAID/Mozambique and PEPFAR, as Mozambique is facing a significant “youth bulge”, with 53% of its population below 17 years old. The combined impact of poverty influenced by socio-economic conditions and the HIV/AIDS epidemic poses a major challenge for this population. Youth continue to lag in achieving the 95-95-95 goal; as of 2021 only 50% were aware of their HIV status, 52.6% of youth (age) were on treatment, and 41.6% had viral load suppression, the lowest compared to the other groups.

As Youth is a priority group for SUCESSO, USAID conducted an analysis of relevant documentation and held consultations with key stakeholders to ensure that this Activity is responsive and inclusive of Youth specific challenges and concerns related to access and retention in health and HIV services. The analysis identified the following factors has barriers for active uptake and maintenance of Youth in health and HIV services: lack of integration of prevention services in health facilities; poor flow and linkages between prevention services;

limited adaptation of health services to youth needs (limited working hours for SAAJs; long waiting hours); discrepancy between demand creation done in the community and schools and the responsiveness and receptiveness at health facilities and by providers; lack of safe spaces for Key populations. The analysis identified concerns regarding the communication and technical capacity of health providers, and their preparedness to work with this group that is transitioning to adulthood, including lack of confidentiality, stigma, and discrimination. Lastly, the HIV status disclosure process was presented as posing a barrier to treatment, as the process can be slow, even though the adolescent already reached the cognitive maturity to understand their status and the role of parents is not well explored despite there being well-developed guidelines for this. The analysis identified the following good practices and interventions that create a youth supportive environment for health seeking behavior and active engagement with health facilities: Youth friendly services (SAAJs); adherence Groups for Adolescents and Young People in Care and Treatment; peer support approach; self-testing; involvement of community leaders in community dialogues and involvement of religious leaders in campaigns targeting adolescents. PrEP was identified as an intervention that triggers a lot of interest in young people, and PrEP and combined prevention (with condoms) was presented as being very appealing to youth, although uptake and perception still need to be improved, thus greater investment in PrEP education was recommended. Improved integration of Prevention services in the health facilities and strengthened health education activities (use of mass media, community radios) have a great potential to mobility youth.

Tailoring interventions to specific age groups, including young boys and girls, adolescent males and females, young women and men, and children under five, is imperative. Moreover, it's crucial that special attention is given to the unique needs of HIV positive youth, ensuring they receive the specialized support necessary to comprehend their HIV status and to equip them with the skills to effectively manage their health.

C.3. Local Systems

The USAID Localization Vision renews the agency commitment to localization by shifting more leadership, ownership, decision making, and implementation to the local people and institutions who possess the capability, connectedness, and credibility to drive change in their own countries and communities.SUCESSO is aligned with USAID vision for Localization and advances USAID/Mozambican strategy towards that vision, to gradually expand its direct support to provincial governments, through Government-to-Government (G2Gs) agreements and to support and build governments and Local Entities efforts to develop sustainable systems for improved and sustained HIV response. This activity is in full alignment with GRM health sector plans.

C.4. Sustainability Sustainability of the PEPFAR program through host government systems is a priority to help ensure ownership and sustain results achieved by PEPFAR over time. SUCESSO is in full alignment with GRM health sector plans and PEPFAR sustainability road map expected by 2024.

C.5. Host Government, Donor, and other Counterpart Collaboration Strong engagement is expected with the GRM on policy issues, alignment with national priorities, joint planning (work plan development), share implementation and performance reports, data, regular coordination, communication with counterparts and, strategic discussion to develop a shared vision for successful implementation of this activity. The Activity will collaborate with other PEPFAR and non-PEPFAR funded program activities to develop synergies to maximize expected outcomes, which include but are not limited to other USAID and USG funded programs, and with other donors, as appropriate.

C.6. Climate Change Integration As per the IHO Health Service Delivery Initial Environmental Examination (IEE), climate risks that potentially affect this activity were rated as moderate and moderate to high and include disrupted access to services and capacity support and damage to infrastructure due to storms, flooding, and drought. Therefore, this Activity will identify expected climate change impacts over the life of the Activity and demonstrate how those risks will be reduced to ensure sustainability of the results expected. An overall Climate Risk Management (CRM) plan is required as part of the EMMP annual deliverable.

C.7. Environmental Compliance Considerations The Activity is covered under the Health Service Delivery Initial Environmental Examination (IEE) valid through June 30, 2027. The proposed interventions in this Activity fall under the categorical exclusion and negative environmental determination categories. The AOR, in consultation with the Mission Environmental Officer (MEO), will oversee the implementation of the requirements in the IEE. In addition, the MEO will approve a Plan for Environmental Mitigation and Monitoring (EMMP) and Environmental Mitigation and Monitoring Report (EMMR) on an annual basis.

C.8. Rapid Response Funds (RRF) As part of this activity, a Rapid Response Fund (RRF) will be established to enable the Recipient to respond efficiently and effectively to rapid-onset natural and/or man-made disasters in the https://drive.google.com/drive/folders/1wsDxbtlkRYP1TKhwAR82v8vRdgc_vQWl https://www.usaid.gov/environmental-procedures/environmental-compliance-esdm-program-cycle/environmental-documentation/emmr activity’s target geographic areas. The purpose of the RRF is to quickly respond to, or mitigate, natural emergencies or crisis originated emergencies, which can lead to the outbreak of disease and challenges in accessing HIV services. Given the potential for known and unknown risks to project implementation, the RRF will have an annual dedicated line item of $100,000 per province per year in the activity budget. Any RRF funds remaining by the end of activity will be de-obligated as part of the final sub-obligation.