RFI AMOSTRA.pdf

SOLICITATION TYPE: REQUEST FOR INFORMATION (RFI)

RFI -656-20- AMOSTRA

PROGRAM NAME: Adapting and Modifying Optimized Sample Transport Routes for

Achieving Impact (AMOSTRA)

ISSUANCE DATE: Monday, May 11, 2020

DUE DATE: Monday, June 1, 2020 at 11:00 am Maputo Time

TO: LOCAL AND LOCALLY ESTABLISHED PARTIES

Dear Potential Offeror, Thank you for your interest in USAID/Mozambique’s Adapting and Modifying Optimized

Sample Transport Routes for Achieving Impact (AMOSTRA). The purpose of this communication is to obtain industry comment on the attached DRAFT Statement Of Objective

(SOO). To that end, information obtained through this RFI will be held in confidence and will not be disclosed to the public unless specifically requested by responding sources.

The U.S. Agency for International Development (USAID), Integrated Health Office (IHO) seeks information to improve the terms of reference for outsourcing transportation system for laboratory specimens including viral load for HIV patients on antiretroviral therapy (ART) HIV

Early Infant Diagnosis (Eid) and tuberculosis (TB) specimens. This RFI is intended to:

- Obtain details concerning partner community interest in the IHO’s anticipated requirement described herein;

- Obtain information on the level of capacity of potential local and locally established partners relative to the tasks and objectives described in this RFI titled “Adapting and

Modifying Optimized Sample Transport Routes for Achieving (AMOSTRA)”;

- Solicit and obtain input, advice, knowledge, and best practices from organizations interested in participating.

While we welcome any comments you may have, we ask that if you chose to respond, that you answer the following questions to assist USAID:

1. TECHNICAL QUESTIONS

When preparing your response to the following questions please ensure comments are concise and specific to the question asked. Responding to each question is not required. USAID values concise, specific and useful responses. For market research purposes, USAID/Mozambique is also interested in your organization’s capabilities, geographic coverage, and experience. All organizations are invited to respond to this RFI. As noted above, please do not submit requests for funding, proposals, or statements of qualifications in response to this request as they will not receive a response.

Please give consideration and respond to the following questions in 300 words or less per response:

a. What is the name of the organization, where it is located and in what geographic areas does it work?

b. What is the size of the organization (staff, budget and/or annual revenue)?

c. Has the organization ever received funding from a national or international source and, if so, what were the amounts and the source(s) received?)?

d. Has the organization received organizational development training such as organizational planning, budgeting, and financial management, or other kinds of organizational training?

If yes, please describe this training.

e. What is the technical area of expertise of the organization?

f. What are the most important things required for specimen transportation nationally? Why do so?

g. Have the organization ever provided this type of service? If yes, describe briefly the services provided.

h. If so, what challenges proved to be barriers or limitations during performance and how could they be mitigated?

i. What type of partnerships and/or alliances that will be necessary to effectively and efficiently carry out the tasks noted in the statement of objectives?

j. Has the organization worked with or supported the Mozambique Ministry of Health

(MoH)? If yes, in what capacity? Please list/describe any challenges.

k. Describe any innovative approaches that will be necessary for transportation and delivery of laboratory specimens including but not limited to, ensuring effective tracking and security of specimens and involving local transporters and community in specimen transportation.

l. Please describe any mechanisms that will be useful to solicit beneficiary feedback in both the design and execution of transportation programs.

2. CONTRACTUAL QUESTIONS

a. Provide the contact information (telephone, email, physical address) of the organization.

Who is the point of contact for donor coordination?

b. Is your organization currently registered in the System for Award Management

(SAM.gov)?

c. Does the organization meets the definition of a Local Established Partner (LEP)?

a. USAID defines a LEP as an international organization that works through locally-led operations and programming models. In addition, LEPs have maintained continuous operations in-country for at least five years and materially demonstrate a long-term presence in a country through adherence or alignment to the following:

i. Local staff comprises of at least 50% of the office personnel,

ii. Maintains a dedicated local office,

iii. Possesses all of registrations.

iv. Maintains a local bank account

v. A portfolio of locally-implemented programs.

vi. Demonstrated links to the local community, including:

1. If the organization has a governing body or board of directors, then it must include a majority of local citizens;

2. A letter of support from a local organization to attest to its work;

and

3. Other criteria that an organization proposes to demonstrate its local roots.

d. Does your organization meet the definition of a local partner?

a. According to USAID, to be considered a “local” organization, an entity must:

i. Be organized under the laws of the recipient country;

ii. Have its principal place of business in the recipient country;

iii. Be majority owned by individuals who are citizens or lawful permanent residents of the recipient country or be managed by a governing body, the majority of whom are citizens or lawful permanent residents of a recipient country; and

iv. Not be controlled by a foreign entity or by an individual or individuals who are not citizens or permanent residents of the recipient country.

1. The term “controlled by” means a majority ownership or beneficiary interest as defined above, or the power, either directly or indirectly, whether exercised or exercisable, to control the election, appointment, or tenure of the organization’s managers or a majority of the organization’s governing body by any means, e.g., ownership, contract, or operation of law. “Foreign entity” means an organization that fails to meet any part of the “local organization” definition.

e. In your experience delivering similar or relevant services, what contract type/mechanism has worked well?

f. Do you have any other feedback or recommendations that you would like to share with

USAID regarding any anticipated solicitation for this requirement?

Responses must include organization’s name, address, point of contact, phone number and e-mail address.

Please submit the requested information by e-mail attachment by the closing date and time shown at the top of this cover letter to Antonieta Manhica at amanhica@usaid.gov. The subject line of the e-mail must read “RFI – AMOSTRA Impact”

USAID/Mozambique will not provide answers to any question submitted in response to this request.

mailto:amanhica@usaid.gov

In accordance with Federal Acquisition Regulation 15.209(c), the following clause is incorporated into this RFI:

“FAR 52.215-3 REQUEST FOR INFORMATION OR SOLICITATION FOR PLANNING

PURPOSES (OCT 1997)

(a) The Government does not intend to award a contract on the basis of this solicitation or to otherwise pay for the information solicited except as an allowable cost under other contracts as provided in subsection 31.205-18, Bid and proposal costs, of the Federal Acquisition Regulation.

(b) Although “proposal” and “offeror” are used in this Request for Information, your response will be treated as information only. It shall not be used as a proposal.

(c) This solicitation is issued for the purpose of gathering information and comments to the SOO

Draft attached to this document.

NOTICE: THIS IS A REQUEST FOR INFORMATION (RFI) ONLY. The RFI is solely issued to gather information for planning purposes as an attempt to identify capabilities of potential contractors and to gain feedback on the draft Statement Of Objectives (SOO).

Therefore, respondents are advised that any information submitted may be used to inform the development of the anticipated Statement Of Objectives (SOO). This RFI is NOT a Request for

Proposal (RFP), a Request for Quotation (RFQ), an Invitation for Bids (IFB), a solicitation or an indication that USAID will contract for the requirement contained in this RFI.

DRAFT STATEMENT OF OBJECTIVE (SOO)

Adapting and Modifying Optimized Sample Transport Routes for Achieving

Impact (AMOSTRA)

INTRODUCTION

To achieve the United States Government (USG) and Government of the Republic of Mozambique

(GRM) health goals, patients must have access to timely and accurate diagnostic technologies to aid in the diagnosis and monitoring of life threatening diseases. The primary purpose of Adapting and Modifying Optimized Sample Transport Routes for Achieving Impact (AMOSTRA) is to provide an effective and efficient transportation system for laboratory specimens including viral load (VL) for HIV patients on antiretroviral therapy (ART), HIV Early Infant Diagnosis (EID) and

Tuberculosis (TB) specimens. This system will operate under the supervision of the GRM and will gradually be transitioned to the government to manage. This directly supports the GRM’s strategic objectives in the Mozambique National Development Strategy (2015 - 2035) that calls for the eradication of large epidemics and the diseases that are the major causes of mortality, including HIV/AIDS, and Tuberculosis. Achieving the reduction of HIV prevalence from 14% in

2015 to 5% in 2035 as called for in the strategy requires an effective laboratory specimen transportation system. Additionally, the Health Sector Strategic Plan (PESS, 2015-2024) calls for strengthening transport systems for laboratory samples.

The activity will be focused on five key objectives: 1) Increased access to diagnostic testing with a focus on HIV VL, EID and TB testing; 2) Improved timeliness of diagnostic test results / shortened turnaround times between specimen collection and return of results; 3) Reducing the cost of specimen referrals by ensuring cost-effective means for packaging, transporting and returning test results; 4) Assured quality of diagnostics testing through proper handling of specimens and test results; 5) Support a national platform for reporting, monitoring, coordinating, and continuous quality improvement of specimen transport. AMOSTRA will expand access to viral load monitoring, EID and TB testing by competitively engaging transporters, including both private sector and community-level transporters, to operate a cost-effective specimen referral system.

BACKGROUND

Mozambique is a rural country of 11 provinces and 29.6 million people1 and ranks low on the

Human Development Index at 180 out of 189 countries.2 Sixty percent of Mozambicans live on less than $1.25/day with a gross national income of $600 per capita.3 Seventy percent of

Mozambicans are estimated to be poor and 37% destitute. National HIV prevalence is estimated at 13%, with substantial variation in provincial prevalence rates and an estimated 1.9 million

COP20 Minimum Program Requirements

Human Development Report, 2018, UNDP

World Bank, 2014 people living with HIV. Of the estimated number of people living with HIV (PLHIV), 45% are currently on Anti-Retroviral Treatment (ART). Mozambique has one of the highest rates of multi-drug resistant TB at 3.5 percent.4 Generally, urban health indicators are much better than rural where access to basic treatment monitoring services and diagnostics is still limited. The country has a slow economic growth trajectory following the 2016 hidden debt crisis and the economic performance has yet to revert to the pre-crisis levels of 7% growth.

The health system faces several major challenges, including limited funding, insufficient infrastructure, and a critical shortage of human resources. Over 90% of Mozambicans live in an underserved primary health care area defined as over a one hour walk from a primary health care center.5 Overall, the ratio of population per hospital bed is 1 bed per 1,038 persons, with substantial variation across the country.6 Human resources for health (HRH) are severely constrained with 7.8 doctors, 26.8 nurses, and a total of 100.2 health care workers (HCW) per

100,000 people.7 Together with uneven geographic distribution and limited supervision, there are an inadequate number of trained and competent health care workers in all cadres. Diagnosis of disease remains a challenge in Mozambique; with VL, EID and TB testing being a notable challenge. Inefficient specimen transport, inefficient laboratory testing process, long turn-around times, and inadequate effort expended to ensure all VL tests results are returned to the patient and used to improve patient management.

The Public Health network of the Country is classified into four levels: Quaternary (Central and

Specialized Hospitals), Tertiary (Provincial Hospitals) Secondary (District, General and Rural

Hospitals) and Primary (Health Clinics). At the moment the service of clinical laboratory service follows the same organizational levels. The National Directorate of Medical Assistance oversees the Department of Clinical Laboratories (DCL). This department in turn coordinates the activities of clinical laboratories in general. The head of DCL coordinates and determines policy guidelines for clinical laboratories. Central laboratories providing for public health are under the

National Institute of Health. The military laboratory which is under the jurisdiction of the

Ministries of Defence operates independently. The University teaching laboratories are under the

Ministry of Education. Private laboratories generally have no formal agreement with the government.

In the provinces, there is a provincial point of contact that is responsible for networking, and reporting to the central level. At the level of the district, there are supposed to be points of contact that supervise activities in the health centers and report to the provincial POCs; however, this structure does not consistently function as it should.

The laboratory specimen referral and diagnostic network is a multi-tiered system where samples are collected, packaged, transported, and analyzed. Specimens must be adequately maintained through sample collection, labelling, picking, packaging, transportation, and storage in a temperature controlled environment. The first tier of the laboratory network includes health facilities that serve as collection sites where health care providers work with a patient to collect

National Tuberculosis Drug Resistance Survey (2010). Mozambique has the highest rate of MDR-TB in Southern Africa.

Luis & Cabral, Geographic accessibility to primary healthcare centers in Mozambique, 2016

MISAU/MOH – DRH. Relatório Anual dos Recursos Humanos. Maputo, Abril 2014

MOH/MISAU, 2016. WHO (2006) estimates 230 medical professionals per 100,000 people as a minimum threshold necessary to provide essential health interventions.

and prepare dry blood spots (DBS), a blood sample or a sputum specimen. For HIV, collection sites may not have the equipment (centrifuges) necessary to separate plasma from whole blood and are limited to taking dry blood spots. The second tier facilities or “collection hubs” serve as a point of collection for other sites as well as samples from their own patients and may be capable of centrifuging whole blood or taking DBS samples (see Figure 1 for example of full VL testing process). As many second tier facilities have GeneXpert instruments, TB specimens are often analyzed at this level. HIV specimens are currently sent for analysis to the 3rd tier laboratories that have specialized technology, equipment, and human resources to complete polymerase chain reaction (PCR) analysis. When specimen is transported in a manner that maintains integrity of the specimen, diagnostic machines analyze the specimen and produce a result, which is then transmitted back to the original referring facility clinician to inform diagnosis and treatment options.

Figure 2.1.1: Process for HIV Viral Load Testing

In order to reach the US Government’s goal of detecting 90% of all TB cases by 2022, Mozambique has to detect 145,800 cases each year – nearly 60% more than the detections over the past year. In addition, of the 92,381 notified cases in 2018, only 39% were bacteriologically confirmed. Not only does Mozambique have to find more than 145,000 additional cases each year, they need to confirm that the cases they have notified truly have TB by way of a bacteriological test using GeneXpert analysis.

In 2018, an estimated 92,700 people were treated for TB; however, TB deaths rose by 22% and

TB cases rose by 16% (from 2012 to 2017). Overall, TB diagnosis stands at 57% of estimated incidence. Of those diagnosed, only 41% percent were diagnosed with rapid diagnostics (WHO

2018 TB Profile for Mozambique). While drug-sensitive and MDR-TB notifications have increased markedly over the last 5 years; an estimated 66% of previously treated/relapsed patients were bacteriologically confirmed to have rifampicin resistant TB. Utilization of

Mozambique’s 288 GeneXpert machines stood at between 35%8. Of Mozambique’s 162,000 estimated TB cases, 58,000 are also HIV infected (36%). While TB/HIV co-infection is a significant problem in Mozambique, HIV is not fully driving the TB epidemic. A large number of TB patients require focused TB diagnostic services as close as possible to where they access health services, to allow for timely diagnosis.

There has been remarkable progress in the number of people on life-saving ART, which reached

1,212,562 in 2019, up from 16,155 in 2005. Growth has been particularly strong in recent years, more than doubling from 2014 and 2019. The number of health facilities offering ART increased from 255 in 2011 to over 1,368 in FY 2019. The number of patients receiving a viral load (VL) test to monitor the effectiveness of their treatment regimen, increased from 390,574 in the first quarter of FY19Q1 to 618,064 in the first quarter of FY20. Viral load suppression has risen from 78% in the second quarter of FY19 to 81% in the first quarter of FY20. The analysis of VL has been one of the most critical tools for switching patients to regimens that will improve their health. The current capacity of the HIV PCR network that is composed of 28 instruments in

14 labs that allows for 936,660 VL & EID tests per year and the network continues to grow. The

14 labs that serve the referral system for VL and EID are continually being optimized to match testing demand, power, productivity and HR capacity and other factors. New machines will be placed within the diagnostic network, as dictated by optimization studies, to continue to grow testing capacity. The most common sample collection is with DBS but the country is gradually transitioning to plasma samples as the primary sample type due to available instrument technology.

There has also been progress in testing infants for HIV through EID sample referrals. The number of infants tested for HIV in 2019 was 117,093, up from 118,731 infants tested in 2018.

In FY 2019, EID enabled PEPFAR Mozambique to increase the number of pediatric patients enrolled on ART to 55,000. While access to EID services has improved over time through the use of 133 point of care (POC) machines and sample referral using dried blood spot collection;

the number of EID tests hasn’t risen as dramatically as expected. Without further expansion of sample collection, referral and results retrieval, many infants will go undiagnosed and will not receive life-saving treatment.

VL samples that are sent from referring sites are logged using the DISA Link system that allows program managers to track sample TATs, including the time it takes to go from taking the sample from a patient to transporting the sample to the lab or health facility with POC instruments (henceforth referred to as “testing site”). As of 2019, this portion of the TAT was approximately 6 days. To keep pace with the growing demand while ensuring competition among vendors, the USG is balancing the number of tests performed on different types of HIV

PCR machines (made by Roche, Abbott, Hologic and Biomerieux.) This mix is likely to evolve over time and the sample transport system must also stand ready to adapt as machines and sampling approaches evolve.

Progress in providing TB diagnosis had improved but with some decline over recent years, due to shortages of GeneXpert cartridges and lack of regular maintenance. The number of TB

Cazabon D, Pande T, Kik S, et al. Market penetration of Xpert MTB/RIF in high tuberculosis burden countries: A trend analysis from

2014 - 2016. Gates Open Res. 2018;2:35.

suspects tested for TB using GeneXpert analysis in 2019 was 65,939, up from 31,975 tests in

2018. The number of health facilities offering GeneXpert testing is 181; which is performed in one of the 185 GeneXpert machines. TB testing continues to play a critical role in ensuring TB suspects receive an accurate TB diagnosis; and 95,919 of presumptive TB suspects were confirmed and enrolled on TB treatment in 2019. Transport distances and turnaround times for

TB Sputum samples are typically much shorter as those diagnostic machines are more widely available at health facilities. TB samples taken at facilities that provide HIV services, are generally transported along with HIV-related samples but are not currently tracked from their point of origin in the way HIV samples are.

PURPOSE AND ACTIVITIES

Purpose

The primary purpose of AMOSTRA is to provide an effective and efficient transportation system for VL for HIV patients ART, EID and tuberculosis specimens. This system will be operated under the supervision of the GRM and should be aimed at reducing the cost of specimen referrals to prepare for a more affordable transition to the government to manage and finance. AMOSTRA will increase access to diagnostic testing while improving the timeliness of diagnostic test results by ensuring shortened turnaround times between specimen collection and return of results.

AMOSTRA will also assure the quality of diagnostics testing through proper handling of specimen and through support of a national platform for specimen transport reporting, monitoring, coordinating, that leads to continuous quality improvement of specimen transport.

Geographic Focus

This activity is envisioned to roll out on a province by province basis until achieving national coverage.

Performance Objectives

The activity will be focused on five key objectives:

1. Increased access to diagnostic testing with a focus on HIV VL, EID and TB testing;

2. Improved timeliness of diagnostic test results / shortened turnaround times between specimen collection and return of results;

3. Reducing the cost of specimen referrals by ensuring cost-effective means for packaging, transporting and returning test results;

4. Assured quality of diagnostics testing through proper handling of specimen and test results;

and

5. Support a national platform for reporting, monitoring, coordinating, and continuous quality improvement of specimen transport.

The five objectives described above support the activity to meet the key performance indicators described below:

Figure 3.3.1: Key Performance Indicators and Targets

Key

Performanc e Indicator

Description of Indicator

Data

Source

Reporting

Frequency

Targets

Pick-ups Numerator

Denominator

The total number of missed pick-ups

The total number of expected pick-ups

Facility specimen signal and visit log

Monthly <1%

On-time specimen delivery

Numerator

Denominator

Total Number of specimen that were delivered within the standard lead time

Total Number of specimen delivered

Specimen

Manifest

Form

Monthly 100%

Specimen

Delivery

Rate

Numerator

Denominato r

Total number of specimen delivered at the testing site.

Total number of specimen dispatched from the collection site

Specimen

Manifest

Form, Specimen

Register

Biweekly 100%

Results

Delivery

Rate

Numerator

Denominato r

Total number of results delivered within set time

Total number of results dispatched from the testing site

Result

Dispatch

Form

Monthly 100%

Number of

Specimen

Numerator Total number of

Specimens collected from the collection site for transportation by type within a defined period

Specimen

Manifest

Weekly, Monthly

TBD on an annual basis

Additionally, USAID anticipates the addition of an indicator to measure user satisfaction and another for the transition to GRM management.

While specific activities are not defined in this statement of objectives, activities must accomplish the objectives above and meet the key performance indicators outlined above. In addition the objectives and key performance indicators, the operating constraints in the following section must also be considered.

C. 3.4 Operating Constraints

Objective 1 - Considerations for increasing access to diagnostic testing with a focus on HIV

VL, EID and TB testing include:

a. Through the implementation of this activity, the offeror should support the development of the local transportation sector as well as community mechanisms for referring specimens. It is expected that transporters not selected to serve as sub-contractors be provided constructive feedback on why they were not selected.

b. Pick up samples for approximately 1,500 sites (this serves as the basis for AMOSTRA but the exact number may change over time, as new sites are activated) and deliver to testing sites (up to 200 sites).

Objective 2 - Considerations for improving timeliness of diagnostic test results / shortened turnaround times between specimen collection and return of results include:

a. Prior to arrival at each health facility, notify the designated contacts of the health facilities/sample processing and storage hub and implementing partners of impending sample pickup and delivery operations no less than 30 minutes before arrival at the respective health facility/sample processing and storage hub and implementing partners.

b. All contacts need to be documented and shared between referring facilities and receiving testing sites such that any delays in return of results, as well as any priority results, can be communicated via phone by the testing site to the testing facility that referred the sample.

Objective 3 - Considerations for reducing the cost of specimen referrals by ensuring cost-effective means for packaging, transporting and returning test results include:

a. Monitor the sample pickup and delivery operations carefully and shall rapidly address any issues that arise including issues of accessibility, vehicle breakdown, lagging delivery times, or security. These issues must be reported as soon as they occur along with proposed mitigation/management measures.

b. Vehicles shall be properly registered, insured, maintained, and include the appropriate packaging for the collection and transportation of stipulated specimen types.

c. Maintain a complete security plan which will include sufficient precautions to ensure that no unauthorized personnel have access to the items being transported. The security plan will be presented to USAID.

Objective 4 - Considerations for assuring quality of diagnostics testing through proper handling of specimen and test results include:

a. Deliver products on time, without loss or damage, and ensure security of products throughout the entire transport.

b. Implement and follow World Health Organization (WHO) Technical Report Series, NO.

957 2010, WHO Technical Report Series, No. 961, 2011 (Model Guidance for the Storage and transport of Time and Temperature Sensitive Pharmaceutical Products), WHO

Guidance on Regulations for the Transport of Infectious Substances 2015-2016

(WHO/HSE/GCR/2015.2), and national regulations. The regulations pertaining to sample handling are subject to updates/changes and implementation must adapt accordingly.

c. The Service Provider(s) shall conduct a reverse run daily or weekly basis (depending on the nature of the test) from the date that samples are delivered to each testing site to pick up hard copy sample result reports that will be delivered to each originating health facility and associated clinical implementing partners, where they have not been transmitted electronically.

d. Submit downloaded temperature logs for every consignment of sample conveyed using digital temperature readers. Provide adequate temperature regulated boxes, with at least

48 hours of cold life, to convey clinical samples that are cold chain dependent. This consists of utilizing passive containers which can be loaded on to an ambient vehicle and maintaining temperature within the required range for the duration of the delivery to point of destination. Provide conditioned ice packs to guarantee optimal storage conditions throughout the sample transportation period. The samples must be protected from condensation from the ice packs or water packs.

e. Maintain and observe strict adherence to patient confidentiality guidelines and infection control measures during all aspects of specimen transport and result retrieval.

f. Ensure proper documentation and chain of custody of samples and results throughout the turnaround time by recording all clinical samples and patients’ results picked up and delivered. All the sample pickup and delivery notes shall have unique reference numbers to be able track samples and corresponding results, be in quadruplicate, must be signed indicating: receipt of the specimen, its condition, temperature of the delivery package, and time of collection/delivery.

Objective 5 - Considerations for supporting a national platform for reporting, monitoring, coordinating and continuous quality improvement of specimen transport include:

b. Regularly engage with the USG and GRM in the route planning process and continually seek to optimize routes and operations, to provide service coverage to the health facilities and testing sites.

c. Present to a national steering committee on a monthly basis to update the committee on overall system performance, bottlenecks and coordination issues.

d. Work will build and maintain close working relationships with USAID, CDC, clinical partners, the DCL, INS, MISAU, and other relevant partners. Collaborate is expected, with the aim of achieving increased VL, EID and TB testing. This includes working closely with the relevant entities (including sites) to establish schedules, expected TAT and vehicle pick-up modalities, requesting feedback and sharing feedback to sites/partners as part of continuous quality improvement process.

e. Maintain close coordination and harmonization of activities with other health implementation partners in the provinces, in the event of an outbreak that requires specimen referral requires use of the specimen referral network.

Local Systems

While the relationship to the MISAU, INS and DCL is described above, it is important to note that these institutions play a critical role in local laboratory systems. As the national reference laboratory, INS is responsible for surveillance, technical training, research, and technical strategy development. DCL is responsible for implementation policy and procedures, technical guidance to labs, and oversight of the clinical lab network. MISAU health programs are responsible for identifying laboratory needs to achieve clinical objectives. As such, the contractor should coordinate and communicate with these institutions via regular update meetings, sharing reports, participating in the medicines technical working group, and generally secure buy in for the approach. USAID and CDC will create a strategy for transition that requires a gradual shift of management responsibility to the GRM. USAID and CDC will assess readiness against key milestones.

Sustainability

USAID recognizes that given the current political, economic and social realities in Mozambique, achieving universal availability of diagnostic testing at the site level requires significant support in order to enable the achievement of USAID and MISAU goals. Therefore, the activities within

AMOSTRA must enhance the future sustainability of diagnostic services and pave the way for an eventual transition of program responsibilities to the GRM or another entity. Activities must strengthen the institutional capacity of the health sector from the central, provincial and district levels, down to health facilities or other collection points. These are systems upon which all health services in Mozambique rely.

Draft plans for transition must be discussed with GRM and other partners to plan for transition and/or phasing out of certain interventions in planning for the end of the activity in a given geography, should funding become unavailable during the life of the activity, and/or when the

GRM or another entity has identified resources to assume or transfer responsibility. Finally, the offeror should collaborate with the GRM colleagues and other donors to explore and support alternative long-term financial solutions to maintain an outsourced medical commodity transportation solution.