RFI for 3S-QI for sam.gov.docx

REQUEST FOR INFORMATION (RFI)

USAID/Cambodia Sustainable System Strengthening for Quality Improvement (3S-QI)

The USAID/Cambodia Mission has developed a DRAFT Scope of Work for a prospective Sustainable System Strengthening for Quality Improvement. 3S-QI is a new five-year health system strengthening activity to improve the capacity of both public and private health systems in Cambodia to provide high quality priority health services, including maternal and child health, and infectious diseases. Building on USAID’s previous investments in health system strengthening and lessons learned from other stakeholders, this activity will further implement the Royal Government of Cambodia’s (RGC) Health Strategic Plan phase 4 (HSP4) in light of the decentralization policy. 3S-QI will work with national and subnational health systems to strengthen the implementation of national policies and standards, to improve private sector quality monitoring systems, and to improve the capacity of providers and institutions to provide better and more sustainable healthcare services. These include, where permissible, and within USAID’s manageable interest, assisting to build an overarching enabling environment for Private Sector Engagement (PSE).

The purpose of this RFI is to provide industry and stakeholders an opportunity to review, comment, clarify, provide suggestions for improvements, and enhance areas in the Program Framework. The anticipated award value is in the range of $20-$30 million. The Draft Scope of Work is provided in the following pages.

DISCLAIMER

This Request for Information (RFI) is issued solely for information and planning purposes. This is not a Request for Proposal and is not to be construed as a commitment by the U.S. Government. Responses to this RFI shall not be portrayed as a proposal and will not be accepted by the Government to form a binding contract. Issuance of this notice does not constitute an award commitment on the part of the Government, nor does it commit the Government to pay for any costs incurred in the preparation of comments. Responders are solely responsible for all expenses associated with responding to this RFI.

Responses to this RFI are strictly voluntary and USAID will not pay respondents for information provided in response to this RFI. Responses to this RFI will not be returned and respondents will not be notified of the result of the review. If a Solicitation is issued, it will be announced on the sam.gov website at https://www.sam.gov at a later date, and all interested parties must respond to that Solicitation announcement separately from any response to this announcement.

INSTRUCTION

Responses (comments, suggestions, and enhancements) to this RFI are due to OAA at the identified e-mail address(es) below by April 7, 2022 at 4:00 pm, Phnom Penh time. Please forward your responses to Ms. Honey Sokry at hsokry@usaid.gov with a copy to phnompenhoaa@usaid.gov with the subject title “Response to the USAID Cambodia Sustainable System Strengthening for Quality Improvement (3S-QI)”

USAID seeks:

· Feedback (comments, suggestions and enhancements) on the design of the program as laid out in Attachment 1.

· A brief statement of interest and capability statements from interested organizations to include:

o Name, email address and address of organization o General organization information o Statement of capabilities (including staff and technical resources) o At least three (3) references for similar programs performed by the organization in the past ten (10) years, including a short technical description and project value.

Attachment 1: Scope of Work Context and Problem Statement:

Cambodia has made significant improvements on its health indicators, achieving 2015 Millennium Development Goal targets for infant mortality, under-5 mortality, maternal mortality, tuberculosis and HIV/AIDS ahead of schedule. However, maternal and newborn mortality rates are still among the highest in Southeast Asia. One-third of children are still stunted from poor nutrition, HIV transmission remains high in specific populations, and Cambodia remains among the countries with the highest burden of tuberculosis. Across the health system, quality of care is a barrier to improved health outcomes.

Maternal and Child Health The 2019 Cambodian population census shows some progress in maternal and child health with the maternal mortality ratio (MMR) at 141 per 100,000 live births and under-five mortality rate (U5M) of 28 per 1,000 live births. However, Cambodia remains in the group of countries with the highest MMR and child mortality rate in South-East Asia. Therefore, extra effort is needed to achieve the new health target of Sustainable Development Goal 3.1 to lower the MMR to less than 70 per 100,000 live births, reduce U5M to 25 per 1,000 live births in 2030 and the neonatal mortality rate from 18 to 12 per 1,000 live births by 2030.

In response to high levels of maternal and newborn morbidity and mortality, Cambodia developed and implemented two consecutive Emergency Obstetric and Newborn Care (EmONC) Improvement Plans for the periods of 2010-2015 and 2016-2020. The EmONC assessment and reviews in 2020 showed the increased number of Comprehensive EmONC Care (CEmONC) and Basic EmONC (BEmONC) facilities. However, Cambodia still has fewer than half of the recommended number of functioning EmONC facilities for the country and EmONC facilities are still largely concentrated at the hospital level and in urban areas, with one province still lacking any EmONC facilities. The needs of newborns with complications are also being insufficiently met. The same assessment showed that 31.6% of the expected number of women who will develop complications were treated in functional EmONC facilities while 0.44% of women treated with obstetric complications in those facilities died. It also showed 1.2% of births in all facilities surveyed were stillborn or died in the early neonatal period. In order to address these and other remaining challenges, a new EmONC Improvement Plan is being proposed for the period 2021-2025.

Family Planning and Reproductive Health (FP/RH) Significant progress has been made for reproductive health and family planning (FP) in Cambodia, but training and quality assurance of health providers on method mix and FP quality assurance (QA) and Quality Improvement (QI) tools still remain a focus of the Ministry of Health (MoH). Capacity of service providers, particularly on long acting and permanent methods continue to be challenges. New staff and new FP method introduction require ongoing in-service education to equip them to provide FP services. A shortage of skilled providers, and common myths and misconceptions are leading people to rely on traditional methods. The 2014 Cambodia Demographic and Health Survey (CDHS) shows that 12% of currently married women have an unmet need for family planning services with 5% in need of spacing and 7% in need of limiting. While most family planning users access services through the public sector, only pills and condoms are shared equally between public and private sectors.

HIV

Cambodia has made significant progress in controlling the HIV/AIDS epidemic in recent years. USAID has helped reduce the HIV prevalence from 1.7 percent in 1998 to 0.6 percent in 2020 by improving the quality of HIV services, developing innovative ways of finding the last cases and improving the cost effectiveness of the HIV response. These efforts have contributed towards achieving a tenfold reduction in new infections, from 11,000 to 1,100 per year. Today, 84% of the estimated 75,000 Cambodians living with HIV know their status, 99% are on medication to control the virus, and 97% of those on medication are virally suppressed, which greatly reduces their risk to transmit the virus. Ending the epidemic will require finding the estimated 12,000 people living with HIV who remain undiagnosed and linking them to treatment. Reducing new infections will also require expanding prevention, particularly through the provision of pre-exposure prophylaxis (PrEP) medication.

In the private sector, availability of HIV services remains limited, with little referrals or sharing of data between public and private sectors. In the public sector, HIV services are largely delivered though vertical parallel systems financed by international donors. Ongoing challenges include the need to integrate HIV into the national system, ensure client-friendly services for key populations (particularly men who have sex with men and transgender women), and increase access and quality of care in the private sector.

Tuberculosis (TB) USAID assistance has improved the quality of TB services and has supported the national TB-control program in reducing TB prevalence and deaths by more than half. USAID is working to improve the quality of laboratories, implement the connectivity system to diagnostic devices, expand screening and prevention, and improve detection rates of new TB cases in underserved areas and ensure treatment success rates of up to 90 percent. With USAID’s contribution, significant progress has been made in the TB control program in Cambodia with the reduction of TB incidence by 50% from 2000 to 2018 according to WHO report. The estimated TB incidence in Cambodia declined from 575/100,000 in 2000 to 423/100,000 in 2011 and 274/100,000 in 2020. In 2021, the National TB Program (NTP) reported 21,627 cases of TB, a significant decrease compared to 2020. While there have been successes in the treatment of drug-susceptible tuberculosis (DS-TB) and multidrug-resistant TB (MDR-TB) in Cambodia, case detection of all types of TB remains a challenge, with almost 50% of cases going undetected which illustrates a large gap in case notification.

There are several factors that contribute to the high number of undetected cases, which include inaccessibility of health care services at the community level, lack of knowledge and awareness of the symptoms of TB, sub-optimum screening and referral at referral hospitals and health centers, and the roles of private sector in these efforts, etc. The burden of MDR-TB in Cambodia is low and NTP identified 72 cases in 2021 which are still undetected.

TB services are mainly provided by the public sector, yet a little information is known on private sectors in TB control. Recently, the national TB program involved pharmacies and private clinics in selected ODs to refer presumptive TB patients to diagnose and treat at public health facilities. As the scale of the private sector has increased and they play a significant role in health care services which poses a question on capitalizing their potential capacity to support NTP in provision of TB services.

Malaria USAID, through the President’s Malaria Initiative (PMI), is also providing technical assistance in malaria by strengthening control, elimination, and surveillance activities, as well as monitoring drug resistance. These programs have contributed to significantly reducing malaria morbidity and mortality in Cambodia over the last 10 years, with zero deaths from malaria since 2018. While malaria rates have dropped dramatically, finding and treating the last remaining malaria cases is a challenge for the national malaria control program and partners. Efforts will focus on expanding screening, social behavior change approaches, and malaria prevention at the community level in forested areas to reach the 2025 elimination target.

Cross-Cutting Health System The current health sector programs are guided by the Health Strategic Plan 2016-2020 (HSP3), which is the third medium term plan of the health sector. The progress of improved service coverage and quality have been observed and mechanisms to support the assessment and monitoring quality have been established in the public sector. Given the rapid growth of private providers with insufficient regulation measures, MoH priorities remain focused on advancing safety and quality of healthcare to maximize the health outcome of the Cambodian people. The interventions include building governance and institutional structures and capacity to direct and support quality improvement efforts in synergized and harmonized manners; building and implementing the Cambodian National Health Accreditation System (CNHAS) for both public and private health facilities in sequenced phases; and improving functional compliance mechanisms by setting out and implementing minimum standards for service quality and safety as guided by the national policies and guidelines.

However, significant challenges persist that constrain the health sector’s ability to address access to quality of healthcare services by the general Cambodians. Lack of broader health insurance, and its links to quality assurance of healthcare services still make Cambodians spend high levels of out-of-pocket spending for healthcare and still expose them to unsatisfied health services.

Health Equity and Quality Improvement Project:

In September 2016, the MoH launched a new five-year program called the Health Equity and Quality Improvement Project (H-EQIP), funded with pooled funding from RGC, Department of Foreign Affairs and Trade, German Government, Korea International Cooperation Agency, and the World Bank. This project uses a multipronged approach to strengthen the health system with emphasis on supporting improvements in quality of care via routine quality assessments in public health systems using the National Quality Enhancement Monitoring (NQEM) tools, improving the availability of critical infrastructure, strengthening public financial management, and incentivizing improvements in the quality of care through Service Delivery Grants (SDG) to health facilities and health management nationwide based on quality assessment results. H-EQIP also supported the Health Equity Fund for the poor to access free public health services. The follow-on project, H-EQIP II will start in July 2022 and end June 2027. H-EQIP II will continue to conduct facility assessments and link scoring results with SDG to the public health facilities. H-EQIP II will revise the NQEM to be called NQEM-2 by using USAID supported Hospital and Primary Health Care Accreditation Standards. In addition, H-EQIP II will expand SDG to link health centers with communities through a focus on key population groups’ registration at health centers, feedback collection, performing noncommunicable disease screening and referral, and health promotion activities. 3S-QI will continue to collaborate with H-EQIP II to support the RGC in advancing Universal health Coverage (UHC) with continued focus on improving financial protection and access to services for the poor and vulnerable, enhancing quality of health services, and strengthening the health service delivery system.

USAID Health System Strengthening Support:

USAID has been assisting to strengthen Cambodia health systems since 2003 with a focus on improving social health protection programs for the poor, health equity funds (HEF); provider and institutional capacity building for quality improvement of public health services for key infectious diseases, maternal and child health, and reproductive health; improving health information systems; and improving logistic management systems. USAID’s assistance in strengthening the HEF system helped the national system to expand to all public health facilities nationwide, allowing more than three million poor Cambodians to access services free of charge. The management of HEF was successfully taken over by the RGC, and USAID continues to support the national capacity to implement the national policy framework on social protection for expanding social health protection for other vulnerable populations. The current USAID support focusing on improved policy, guidelines and tools to promote better harmonization of quality improvement within health systems in both public and private sectors, improved tools and standards for better regulation and accreditation, enhanced capacity of subnational system to implement quality improvement collaborative efforts, and improved quality of preservice training, Private Sector According to CDHS 2014, 67% of Cambodian household members visited private sector providers for their first-time treatment of illnesses or injuries. While some services with acceptable quality exist, especially in not-for-profit facilities, quality controls for private services are still lacking and the private sector remains unregulated mainly because the laws and regulations are still underdeveloped, there is a lack of quality assurance standards, and a lack of enforcement for the implementation of existing laws. Common quality concerns in the private sector include overdiagnosis and overtreatment, leading to high out-of-pocket costs, mistreatment, and under-referral of suspected infectious disease cases to public hospitals. The capacity of private providers varies according to each health profession. Private pharmacies are a major source for healthcare seeking due to their geographic proximity, convenient opening hours, availability of a range of medicines, simple and quick care, and low cost compared to health facilities. The provision of treatment may not fully comply with the national guidance and the pharmacists have been largely left out of training on update diagnosis and treatment guidelines set by different national programs. The introduction of the continuing professional development for in-service training for healthcare providers according to the Continuing Professional Development (CPD) policy-framework is still at the early stage and not well with the national programs’ training. Most healthcare providers are dual practice, with the advantage of receiving updated training from the national levels. However, their actual application of trained skills at their private practice is not well monitored for compliance.

Getting the private sector on board towards better healthcare quality for all Cambodians has proven to be a major challenge in the past, likely due to a lack of coordinating mechanism and influenced by the widespread element of dual practice in Cambodia, where public-sector providers also operate in the private sector. Greater engagement with the private sector in the development of a quality framework and system development is key to securing their support and commitment to national efforts toward enhancement of quality healthcare.

A combination of implementation of regulations for both practitioners and private facilities, complemented with the implementation of H-EQIP II for public systems, and a strong accreditation system, is needed to bring the quality of Cambodian healthcare up to regional standards. There is opportunity for the accreditation system to provide incentives for private providers by publicly recognizing providers that are accredited and operate according to quality standards. The RGC direction to expand social health insurance toward UHC, and the implementation of strategic purchasing, will also serve as motivating factors for improvement of healthcare services in Cambodia through conditional contracting by the insurance institutions.

Integration of Donor Funded Programs:

With funding support from the Global Fund (GF), Cambodia has made significant progress toward infectious disease prevention, control and treatment outcomes for TB, HIV and Malaria. However, the reduction of external funding will pose challenges in sustaining gains made through vertical programming as programs are transitioned into the overall health system. The integration of priority infectious disease services within both public and private healthcare systems are needed, as well as efforts to sustain community participation and response.

In response to these challenges and with the aim to build a Cambodia healthcare system that is resilient, sustainable, effective and efficient, USAID is designing a new five-year health system strengthening project, “Sustainable System Strengthening for Quality Improvement (3S-QI),” which will build on previous investments from the USAID Enhancing Quality of Healthcare Activity (EQHA) and in line with the existing and forthcoming health sector strategies, and in synergy with other development partners’ efforts.

Theory of Change:

If Cambodian health policies are improved, private and public health service delivery is better regulated and responsive to the public, and if quality healthcare is available to all, then Cambodians will have improved health outcomes.

Purpose: Enhanced quality, sustainability and responsiveness of health services in the public and private sectors to maximize health outcomes among Cambodians, including vulnerable populations.

Objective 1: Improved evidence-based policy, guidelines and strategies for more effective and efficient health service systems.

The Activity will provide technical assistance and facilitate system thinking among key stakeholders, including coordinating institutions and national programs/centers leading key vertical interventions, to generate and package evidence, conduct policy analysis, and develop, advocate and support the adoption of feasible, efficient and sustainable policies, guidelines, and strategies for improving the quality and availability of healthcare services at all levels. These strategies will promote the integration of national vertical programs into the mainstream health systems where possible. The analysis and improvement of health system policy will have to consider other factors including greater private sector involvement, human resource development and management, capacity of the subnational systems to lead and monitor the improvement process, patient-centered services, communities of practice among healthcare providers and managers, and community participation. The effective implementation of set policies by the national institutions at subnational levels will depend significantly on the clear standards provided by the national levels. Therefore, the Activity will implement this approach with strengthened coordination at national level and in line with RGC D&D policy. The implementation of this objective will also take into account gender and inclusive development[footnoteRef:1],[footnoteRef:2]. [1: https://www.usaid.gov/GenderEqualityandWomensEmpowermentPolicy] [2: https://www.usaid.gov/inclusivedevelopment]

These interventions will work in coordination with the implementation of H-EQIP II and the Global Fund-funded activities within the public health system. The Activity will also build on USAID and other investments in health information systems by working with service providers and managers in both the public and private sector to use data for more effective planning for continuing quality improvement.

3S-QI will support expanding professional networks in the public and private sectors that can foster technical exchange among healthcare professionals, and compile information as a technical resource center from which healthcare institutions of both sectors can refer and seek technical assistance or services when needed for their quality improvement efforts.

Objective 2: Improved individual and institutional capacity of the public and private sectors to implement, monitor and evaluate quality assurance according to the national standards The Activity will build on current USAID programming, which aims to improve national and local capacity to provide safe, timely, quality and effective health services across the continuum of healthcare needs. The Activity will continue to build the capacity of the private sector, which should be better engaged, regulated and recognized by the RGC/MoH. The Activity will support the implementation of existing and new regulations and accreditation laws in the health sector. While MoH and DPs help set up the monitoring and evaluation systems of quality of public health services, the Activity will focus on implementation of quality standards as well as strengthening monitoring and evaluation of quality compliance and recognition systems of private sector services. This activity will also look at the challenges faced by public health care systems, and provide technical support or facilitate the process of quality improvement at subnational systems, and promote synergy with the implementation of H-EQIP II.

Objective 3: Improved individual and institutional capacity of subnational health systems to provide quality services to address emerging national program priorities In addition to addressing quality improvement challenges in public and private sectors, this activity will also support the national vertical programs (including infectious diseases, reproductive and maternal health) to strengthen vertical disease service delivery at public and private health facilities, and apply updated global, regional and national guidelines using integrated approaches. This Activity will work with relevant national programs to identify priority issues and facilitate or provide technical assistance from national level to subnational level, and may also bring external experts to support these efforts. The areas of support may include training, coaching or exchange on updated technical diagnosis and treatment guidelines to be implemented by service delivery points. The Activity may also support the introduction of innovative approaches that can be jointly defined by the national programs and other stakeholders (such as the GF and H-EQIP II).