C3HP HIV_TB PWS-Updated_09102020.pdf

COMPREHENSIVE CLIENT-CENTERED HEALTH PROGRAM

HIV AND TUBERCULOSIS ACTIVITY (C3HP-HIV/TB)

PERFORMANCE WORK STATEMENT

ACRONYM LIST

AYFHS Adolescent and Youth Friendly Health Services ANC Antenatal Care ART Antiretroviral therapy AQL Acceptable Quality Level C3HP Comprehensive Client-Centered Health Program CBH & SWP Community Based Health & Social Welfare Program CECAP Cervical Cancer Prevention CHS Community Health Strategy CHW Community Health Worker CTC Care and Treatment Centre.

CQI Continuous Quality Improvement CDCS Country Development Cooperation Strategy COR Contract Officer’s Representative DFID British Department for International Development DR-TB Drug Resistant Tuberculosis FP Family Planning GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GOT Government of Tanzania GUC Grants Under Contract HPV Human Papillomavirus HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HSSP Health Sector Strategic Plan iCCM Integrated Community Case Management IEE Initial Environmental Examination mCPR Modern Contraceptive Prevalence Rate MDR–TB Multidrug-Resistant Tuberculosis MEL Monitoring, Evaluation and Learning MNH Maternal and Newborn Health MOHCDGEC Ministry of Health and Social Welfare, Elderly and Children

NMNAP National Multisectoral Nutrition Action Plan NMSF National Multisectoral Strategic Framework PEPFAR U.S. President’s Emergency Plan for AIDS Relief PMI U.S. President’s Malaria Initiative PO-RALG President’s Office – Regional Administration and Local Government PWS Performance Work Statement RMNCAH Reproductive, Maternal, Newborn, Child and Adolescent Health SBC Social Behavior Change SDG Sustainable Development Goal TB Tuberculosis TBD To be Determined TDHS Tanzania Demographic Health Survey UNAIDS United Nations Programme on HIV/AIDS USG United States Government WHO World Health Organization

I. INTRODUCTION

The purpose of this contract is to implement USAID/Tanzania’s Comprehensive Client-Centered Health Program – HIV and Tuberculosis (C3HP-HIV/TB) activity. USAID/Tanzania intends to support the Government of Tanzania’s (GOT) Ministry of Health and Social Welfare, Elderly and Children (MOHCDGEC) and the President’s Office- Regional Administration and Local Government (PORALG) at the central level and in target Mainland regions to deliver high-quality integrated HIV and TB prevention care and treatment services that will improve health outcomes, particularly for youth and women.

The acquisition will increase the demand for and use of quality integrated HIV and Tuberculosis services in target regions by improving access to quality services in both facilities and the surrounding communities, promoting positive health-seeking behaviors among Tanzania’s populace, and enhancing the overall policy environment for HIV/TB service delivery.

II. ACTIVITY BACKGROUND

Incidence of HIV infection has declined dramatically in the last decade and access to antiretroviral therapy (ART) has accelerated rapidly. Nevertheless, the world is challenged to achieve the UNAIDS “95-95-95” goal for 2030 (95% of people living with HIV know their HIV status; 95% of people who know their status are on treatment; and 95% of people on treatment have suppressed viral loads). In 2002, the Global Fund to Fight AIDS, TB, and Malaria (GFATM) was formed to accelerate the end of these diseases as epidemics.

These international platforms are complemented by two U.S. government initiatives, the U.S.

President’s Emergency Plan for AIDS Relief (PEPFAR), initiated in 2002 in response to the global HIV/AIDS pandemic, and the U.S. President’s Malaria Initiative (PMI), launched in 2005 to reduce the burden of malaria and help relieve poverty on the African continent. Additionally in 2018, USAID Administrator announced the USAID Global Accelerator to end Tuberculosis. This initiative catalyzes investments across multiple countries and sectors to end epidemics while building the self-reliance of countries to take action against TB.

Tanzania’s Vision 2025 aims to see the country transform from a least-developed economy to a middle-income economy, which will require high quality human capital and the strengthening of social services, particularly for health and education. In the coming decades, the GOT MOHCDGEC will play an instrumental role in ensuring that healthy individuals, families, and communities are contributing to the country’s broader socio-economic development. To that end, USAID/Tanzania supports and works in close collaboration with these two entities and their respective President’s Office-Regional Administration and Local Government bodies (PO-RALG) and other local government authorities to improve access to and use of quality health care services

– including RMNCAH, malaria case management, TB, and HIV/AIDS – to ensure Tanzania’s citizens are capacitated to live healthy and prosperous lives.

According to the Tanzania HIV Impact Survey (THIS) 2016/2017,1 the prevalence of HIV among adults age 15-64 years in Tanzania is 5%, meaning that some 1.63 million2 adult Tanzanians are living with HIV. The prevalence of HIV among children age 10-14 is less than 1%. Projections from the UNAIDS Spectrum 2020 model show that new HIV infections, now estimated at 0.3% for adults, have been declining steadily over the years, as have deaths for people living with HIV.

Tanzania is committed to achieving the global “95-95-95” goals. While still challenged to reach the first “95” (only 61% of people with HIV in Tanzania are aware of their HIV status), the country has made excellent progress toward the second “95” (94% self-reported current use of ART), and the third “95” (viral load suppression among HIV-positive adults is 87%). Hidden behind these figures are the disparities that exist by age group, gender, geographic region, and urban/rural location. For example, only 52.4% of men know their HIV status compared to 65.3% of women, and only 18% of children are virally suppressed compared to 87% of adults.

Heterosexual transmission remains the main mode of transmission of HIV infections in Tanzania.

Comprehensive knowledge of HIV has declined among adolescents and young people. Among women aged 15-19 years and 20-24 years, comprehensive knowledge declined progressively from 39% and 50% in 2003-2004 to 32% and 43%, respectively in THIS 2016-2017. Similarly, among men aged 15-19 years and 20-24 years, there was a decline from 43% and 57% in 2003-2004 to 33% and 41%, respectively in 2016-2017. Just as comprehensive knowledge has declined, unsafe sex behavior has increased in all age groups for both women and men. Among people who had sex in the 12 months prior to THIS survey, 56% of men and 36% of women had sex with a non-cohabiting, non-marital partner in 2016-2017 compared to 46% and 23%, respectively in 2003- 2004. Among women and men, the percentage was highest among teenagers and then declined with age.

TB and drug-resistant TB (DR-TB) are major causes of illness and mortality in Tanzania, which is among the 30 highest-burden countries for TB and TB/HIV coinfection. Approximately 22,000 Tanzanians die every year due to TB. The current treatment coverage for TB is only 44%. Further, of the estimated 1,700 multi-drug-resistant TB (MDR-TB) cases in 2018, less than 25% were started on MDR treatment. Although it is declining, Tanzania also experiences high rates of TB/HIV coinfection, with World Health Organization (WHO) estimating that almost one third of those newly diagnosed with TB are also HIV-positive. In 2019, the coverage of TB preventive treatment (TPT) among people living with HIV who attend antiretroviral treatment (ART) services reached 60%, with a high completion rate of 86.4%. Nevertheless, poor access to effective diagnosis of TB using GeneXpert, coupled with supply chain issues in peripheral health facilities, make further narrowing this gap a challenge. Furthermore, TB contact tracing for both HIV/TB infected individuals and for the children of smear positive patients is limited. In 2018 WHO reported that only 22% of under-fives received TPT.

As indicated above, the GOT has made significant progress in addressing health concerns across the country. But much remains to be done to enable all Tanzanians to live healthy, productive lives. There are significant discrepancies between rural and urban health facilities, with rural facilities facing more challenges. Further, new evidence indicates that urban areas also face

1Tanzania HIV Impact Survey (THIS) 2016/2017 https://www.malecircumcision.org/resource/tanzania-hiv-impact-survey-2016%E2%80%922017-final-report 22020 Spectrum estimates, 2019-point estimate https://www.malecircumcision.org/resource/tanzania-hiv-impact-survey-2016%E2%80%922017-final-report https://www.malecircumcision.org/resource/tanzania-hiv-impact-survey-2016%E2%80%922017-final-report significant barriers to accessing services, including those related to quality of care. Key constraints include:

● Inadequate human resources for health

● Inadequate budget allocation and disbursement of funds for health

● Shortages of commodities and medical equipment and supplies

● Overall weaknesses in the health system

● Inefficient referral systems and linkages between facilities and communities

● Limited access to health insurance; informal payments at health facilities pose financial barriers to access

● Limited private sector engagement

● Resistance to expanding the role of community-based service delivery

● Limited citizen engagement in promoting public sector transparency and accountability

● Slow adoption of global best practices and newly recommended curative and preventive interventions

● Harmful social and gender norms that affect individuals’ access to and use of services, especially for women, men and youth

● Challenges in reaching facility-based services due to long distances and difficult terrain

● Long waiting times for services at health facilities

● Limited political support for FP provision at the highest level of government

● Inadequate use of data for decision-making and program improvement

To date, inadequate attention has been paid to changing behaviors by addressing factors such as knowledge, attitudes, norms and automatic or unconscious determinants (such as present bias which may affect adherence to ARVs among asymptomatic or younger PLHIV), including communication between health providers and clients, families’ and couples’ communication, and the engagement of community leaders and other influencers in promoting the adoption of healthy behaviors and practices. Arming communities, families, and healthcare workers with the right skills to support self-efficacy and adherence and information is essential to maximizing access to and use of HIV/TB services to save lives and improve health.

In its fourth NMSF for HIV and AIDS, the GOT identified three key priorities: (1) acceleration and intensification of targeted, high impact interventions aimed at preventing new HIV infections and reducing AIDS-related deaths; (2) promoting efficiency and effectiveness, strategic partnerships, and meaningful participation by all stakeholders, in particular communities, in implementation of the national decentralized HIV response; and (3) leveraging the financial, technological, and human resources necessary to sustain implementation of the HIV response.

In Tanzania, to improve the provision of health services at the community level and to help address human resource constraints, the MOHCDGEC developed policy guidelines for Community-Based Health and Social Welfare Services, 2020, and National Operational Guidelines for Community- Based and Health Care Services, 2020 Guidelines3. These guidelines, which are in line with the national HSSP IV, map an integrated and coordinated national approach to community-based health, and will guide operationalization of community-based health services so that the program overall becomes functional and sustainable in improving community health and social welfare.

3 https://drive.google.com/drive/u/0/folders/1ajCu9TH-3y0bH3rRGnfcdLw1R9QkvoZA

Over the past several years, to enhance the effectiveness of its investments and improve health outcomes, USAID/Tanzania’s Health Office moved from a disease-specific and single-service component portfolio to a more comprehensive and integrated portfolio. The Comprehensive Client-Centered Health Program (C3HP) builds on lessons learned from that experience and emphasizes “smart integration” between components and other activities where feasible and possible, strengthens integration and linkages between health facilities and the community, addresses concerns with the enabling environment, and incorporates robust social and behavior change (SBC) interventions at the facility and community levels as a crucial component for success. Critically, C3HP also emphasizes reaching young Tanzanians with health services and health promotion messaging.

C3HP includes three related activities.This current procurement action covers only the two HIV/TB Activities: Client-Centered Health Program HIV and Tuberculosis Activity (HIV/TB) and Local Organization Client-Centered Health Program HIV and Tuberculosis Activity (LOC-

HIV/TB)

● CH3HP- RMNCAH Activity: This award will focus on improving the quality of RMNCAH services at the facility and community level and include community-level SBC interventions.

● CH3HP-HIV/TB Activities: These two awards will focus on the provision of integrated HIV and TB prevention, care, and treatment services, will integrate FP into these services, as appropriate, and include community-level SBC interventions.

These three awards will be complemented by a malaria control program and a national social behavior change technical assistance award (a follow-on to the current USAID-supported Tulonge Afya activity, which ends in 2022). It is envisioned that the three C3HP activities, the malaria control program and Tulonge Afya follow on activities will synergistically collaborate, especially in areas with geographical overlap, to fast track the achievement of the overall goal of improved health outcomes for all Tanzanians.

Regions in which each C3HP award will work are indicated in the table below.

Table 1: C3HP Awards and Regions

Region RMNCH FP Malaria HIV/TB LOCAL

HIV/TB

Geita x x

Simiyu* x x

Mwanza* x x x

Mara* x x x

Shinyanga x x

Katavi x

Tabora x

Manyara x x x

Dodoma x x x

Tanga x

Dar es Salaam x

Arusha x x

Zanzibar x x x

Pwani

Kigoma

Rukwa

Songwe

Iringa X

Lindi X

Morogoro X

Mtwara X

Njombe X

Ruvuma X

Kilimanjaro x

Singida x

Kagera x

III. RELATIONSHIP TO USAID COUNTRY DEVELOPMENT COOPERATION

STRATEGY RESULTS FRAMEWORK

The C3HP-HIV/TB activities are key to achieving USAID/Tanzania’s Country Development Cooperation Strategy (CDCS) for the period 2020-2025. The CDCS focuses on youth as the current and future drivers of Tanzania’s long-term development and prosperity. It emphasizes the needs of youth and young adults for quality public and private sector services that build their skills and productivity, while also focusing on the need for local leadership to create the community environment that allows young people to thrive in a way that will accelerate inclusive, broad-based growth.

The CDCS posits that IF Tanzania improves the foundational skills of its youth; empowers and increases the productivity and engagement of young adults; and strengthens the ability of state and non-state actors to benefit future generations, THEN youth will be better positioned to contribute to the long-term prosperity of their country.

Following the CDCS development hypothesis, the C3HP-HIV/TB Activity will support Development Objective on Foundational skills of children below age 15 improved, with intermediate results on household nutrition and health outcomes improved and safe and supportive community structures enhanced by improving availability and access to HIV/TB services through quality improvements and improved health behaviors at facility and community level. It will also support development objective on empowerment, productivity and engagement of Tanzanians aged 15 to 35 increased with intermediate results on health and education outcomes improved by expanding youth access to quality information and supporting youth in taking control of their own health. The other development objective is capacity of state and non state actors strengthened to benefit future generations with results on capacit of sub national government to lead sustainable development improved, through mentoring, training, supportive supervision and capacity-building at various levels of the health system; and capacit of civil society actors strengthened through strengthening linkages between health facilities and communities.

IV. PERFORMANCE WORK STATEMENT

USAID/Tanzania’s purpose for the C3HP - HIV/TB activity, is increased demand for and use of quality integrated HIV/TB services, particularly by youth and women, leading to improved health outcomes.

To accomplish this, the Contractor must provide technical and material assistance and/or administrative and management support to the GOT-MOHCDGEC and PORALG through local government authorities, at regional and districts level, health facilities and communities to increase their capacity to manage and deliver quality HIV/TB services within public sector and relevant faith based health facilities. The Contractor must also strengthen the provision of community-based health services and improve linkages between communities and health facilities.

All HIV/TB interventions implemented under this activity must be guided by the PEPFAR Country operational plan, TB Road map and MOHCDGEC soon to be released Strategic Plan (HSSP) V (2020-2025), the National Multisectoral Strategic Framework (NMSF) for HIV and AIDS (2018/19-2022/23), the National Strategic Plan V for TB and Leprosy (2015-2020) and its forthcoming successor Plan VI, and the recently launched National Family Planning Costed Implementation Plan (2019-2023).

The goal for the C3HP-HIV/TB Activity and the strategy for achieving results are indicated in the Results Framework (Figure 2) graphic, outlined in the development hypothesis, and discussed in more detail by result and sub-result, below:

Figure 2: C3HP-HIV/TB Activity Results Framework

C3HP-HIV/TB ACTIVITY DEVELOPMENT HYPOTHESIS:

IF: (1) Beneficiaries, particularly children, youth and women have access to integrated, quality HIV/TB services in facilities and communities; and IF: (2) positive social and gender norms and practices related to health-seeking behaviors are strengthened; and IF: (3) the right policies are in place and clients are engaged in service delivery; THEN Tanzanians, especially youth, will use these services, leading to healthier lives and thriving communities.

Geographic Coverage

1. PEPFAR Tanzania reviewed epidemiologic data and burden of disease at the council level, including population density and total number of PLHIV and unmet needs for ART. Based upon progress made in service delivery and revised PLHIV estimates, key interventions will be prioritized in districts with greatest burden and gap in coverage. The C3HP HIV/TB (1) Activity will operate in five regions - Arusha, Dodoma, Kilimanjaro, Manyara, Singida; and the LOC

Goal: Household nutrition and health outcomes of Tanzanians improved

Result 1:

Improved access to quality client-centered health services

Sub-Result 1.1

Improved access to quality health services at both facility and community level

Sub-Result 1.2

Strengthen capacity of health work force to deliver client centered services

Result 2:

Improved ability of individuals to practice positive healthy behaviors

Sub-Result 2.1

Improved attitudes and norms related to health-seeking behaviors

Sub-Result 2.2

Increased community support for healthy behaviors

Result 3:

Enhanced enabling environment for quality health service provision

Sub-Result 3.1 Improved availabilty of quality strategies, policies and guidelines to support healthservice delivery

Sub-Result 3.2

Increased engagement of communities and citizens for quality health delivery

Sub-Result 3.3 Increased engagement and use of systemwide reforms and governance structures that impact service provision

Objective: To increase use of quality HIV/TB services, particularly by youth and women

HIV/TB (2) Activity (restricted to local partners) in six regions - Iringa, Lindi, Morogoro, Mtwara, Njombe and Ruvuma

To improve health outcomes and ensure that services are client centered, the Contractor will integrate HIV and TB and family planning. The contractor will use PEPFAR funds to provide HIV/FP integration services and FP funds to provide family planning services beyond HIV/FP integration in regions of Dodoma, Manyara and Arusha. Furthermore, as further described in Section VII, the contractor will collaborate with the implementing partners of other USAID-supported health services in the identified regions to maximize activity impact.

V. RESULT AREAS

It is anticipated that the C3HP-HIV/TB Activity will contribute to the results framework and indicators as outlined in the following discussion, and to results measured by the following:

1. Epidemic control 95-95-95 (disaggregated by gender/age)

2. MCPR

3. Adolescent pregnancy

4. The number of TB cases detected and notified.

5. Number of MDR TB patients detected

6. Number of TB patients confirmed with Molecular Diagnostic method

7. Number of patients who completed TB preventive treatment

Intermediate Result 1: Improved access to quality, client-centered HIV/TB services

● Sub IR 1.1 – Improved access to quality health services at both the facility and community level

● Sub IR 1.2 – Strengthen capacity of health work force to deliver client centered services

Poor linkages between health facilities and community-based service delivery structures further impact the continuum of HIV and TB care. Furthermore, harmful social and gender norms in many communities negatively impact health-seeking behavior, often limiting clients’ access to and use of facility and community-based services.

Improved access to and use of quality, client-centered health care at both the facility and community levels is essential to improving health outcomes in Tanzania. The contractor must build capacity at both levels to deliver standardized, evidence-based quality HIV and TB services that are client-centered. The contractor will also strengthen bi-directional linkages and referrals within and between health facilities and the community service delivery structures. Where feasible and possible, the contractor will integrate services to make them more client-centered.

Expected Results for this IR will be measured by the following standard indicators:

Mandatory Result Performance Standard4 Improved coverage of HIV testing services/ Increase number of index positives being identified through index testing modalities

1. HTS-TST

2. HTS_TST_POS

3. HTS_Index

Improved linkages to and= retention on HIV Care and viral load suppression

4. TX_CURR

5. TX_NEW

6. TX_PVLS

7. PrEP_CURR

8. TX_RTT

Strengthened TB screening through integrated approach and improved TB outcomes

9. TB_PREV

10. TB_STAT

11. TB_ART

4 A full description of all these indicators can be found in PEPFAR Monitoring, Evaluation and Reporting Indicator Reference Guide MER 2.0 Version 2.4 September 2019 -https://www.state.gov/wp-content/uploads/2019/10/PEPFAR-MER-Indicator-Reference-Guide-Version-2.4-FY20.pdf https://www.state.gov/wp-content/uploads/2019/10/PEPFAR-MER-Indicator-Reference-Guide-Version-2.4-FY20.pdf https://www.state.gov/wp-content/uploads/2019/10/PEPFAR-MER-Indicator-Reference-Guide-Version-2.4-FY20.pdf

12. Proportion of presumptive TB specimen evaluated with molecular testing

13. Drug susceptible (DS) TB treatment success rate

14. Number of clients treated for active TB.

15. Number of MDR TB patients started on second line TB medicines

16. Number of MDR TB patients cured

Strengthen the inclusion of gender -based violence (GBV) screening

17. Gen_GBV

Integrated FP services 18. FP INT_SITE

19. Number of clients accepting a modern family planning method (Disaggregated by Sex, Age (10-14, 15-19, 20-24, or 25+), Contraceptive method, Type of user (new or continuing) and Type of service (routine or outreach)

Strengthen capacity of health work force to deliver client centered services

20. SC_ARVDISP

21. HRH_CURR

22. HRH_Staff(disaggregated by facility and community staff)

Sub IR 1.1 – Improved access to quality health services at both the facility and community- level

Access to quality HIV/TB services is key to meeting beneficiaries' needs, reaching the country’s goal of epidemic control, and helping Tanzanians stay healthy.

To achieve this sub-IR, the Contractor will build capacity to deliver HIV and TB services within all public health facilities in the identified regions, with a focus on improving quality and patient-centered care and treatment.

The offeror will be expected to improve health services across the HIV cascade. Starting with the first 95, identification of HIV positive people, the contractor will address the broad gaps in coverage across age and sex bands through enhanced, evidence-based implementation of key aspects of client centered HIV prevention, case finding and testing approaches:

● index testing that comply with WHO safe measures

● optimized provider-initiated testing and counseling (PITC)

● Pre exposure prophylaxis (PrEP)

● Self testing

● Gender based violence screening and gender norms

● client centered targeted community testing, including peer/social network testing (SNT) approaches for priority populations where new diagnoses are occurring.

● scale up TB case detection, prevention and treatment

● targeted SBC activities for demand creation and stigma reduction

Special emphasis will be on the quality of index testing services ensuring these are client-centered, safe, non-coercive, private, and confidential. This will include routine tracing of intimate partner violence and reporting of any related adverse events. The offeror will outline how it will prioritize case finding, especially among men, and AGYW.

The Contractor will continue to strengthen the collaboration with the Government of Tanzania and OVC service providers to ensure wider scale up of risk screening for HTS especially at medical outpatient department (OPD) and community settings. This will include ensuring the proper use of the validated national risk screening tool.

The Contractor will establish a standardized and coordinated quality assurance (QA) system for HTS; focusing on both QA for Index testing and Optimized PITC performed by HCWs including support of all services for people diagnosed with HIV at those facilities .

For the second and third 95s, the contractor will ensure linkage to treatment, retention and adherence resulting in viral suppression. Technical assistance will be given to facility and community level services to ensure implementation of evidence based care and treatment approaches which include

• transition of optimal regimens for both children and adults.

Integration of TB screening, treatment and preventative therapy, nutrition monitoring, cervical screening and family planning.

Differentiated service delivery models including multi-month dispensing Use of Orphans and vulnerable chilren platforms for pediatric HIV case finding, linkage to treatment, and viral suppression

Establishment of the memorudum of understanding for improved coordination and implementation between health facilities and the OVC program on data sharing agreements ,bi-directional referral protocols and index testing of OVC.

Expected Results:

At a minimum, the Contractor must demonstrate improvements in the following indicators in each of the activity’s target health facilities:

Mandatory Result Performance Standard Improved coverage of HIV testing services/ increase the number of index positives being identified through index testing modalities

1. HTS_TST_POS

2. HTS_Index

Improved linkages to and retention on HIV Care 2. TX_CURR

3. TX_PVLS

4. PrEP_New

5.

Strengthened TB screening with fidelity for case detection through integrated approach to HIV and TB screening.

6. TB_PREV

7. TB_STAT

8. TB_ART

Strengthen the inclusion of gender -based violence (GBV) screening

9. Gen_GBV

Integrated FP services 10. FP-INT

11. Number of clients accepting a modern family planning method (Disaggregated by Sex, Age (10-14, 15-19, 20-24, or 25+), Contraceptive method, Type of user (new or continuing) and Type of service (routine or outreach)

Sub IR 1.2 – Strengthen capacity of health work force to deliver client centered services

When appropriately designed and implemented, community health worker (CHW) programs can play an important role in reducing inequitable access to services by bringing information, services, and supplies to women and men in the communities where they live and work rather than requiring them to visit health facilities.

The Contractor shall collaborate with the established USAID Human Resources for Health (HRH) mechanism in identification of HCWs needed in supported sites using evidence driven approaches and jointly co-manage the contracted facility HCWs with the HRH Mechanism for a performance based assessment associated with their roles and responsibilities as defined.

The Contractor will directly support Community Health Worker (CHWs) per the national and PEPFAR guidance and will use evidence-based approaches to determine the need, services and location of their placement. The contractor will support both the facility and community HCWs by building the capacity of required skills for these HCWs to provide integrated services not limited to, skills for application of service delivery guidelines, provide supportive supervision, job aides, on-the-job training and additional incentive as required.

At a minimum, the Contractor must demonstrate improvement in the following indicators in each of the activity’s target health facilities/communities:

Mandatory Result Performance Standard Strengthened capacity of health work force to deliver client centered services

1. HRH_CURR (disaggregated by facility and community staff)

2. Annual inventory for supported HCWs disaggregated by region, district, facility/site, cadre, type and level of support

3. Increased number of clients treated for active

TB.

4. Increased number of TB clients cured

5. Percent of facility health staff that have at least two health workers trained in the provision of FP services.

6. Percent of community health workers that have been trained on FP.

Intermediate Result 2: Improved ability of individuals to practice positive health-seeking behaviors

● Sub IR 2.1 – Improved capacity, motivation and enabling environment related to health-seeking behavior

● Sub IR 2.2 – Increased community support for healthy behaviors

Availability and good coverage of quality health services is not always enough to achieve intended health outcomes; changing the health-seeking behaviors of individuals and communities, as well as the norms that underpin those behaviors is also required. SBC program evaluations have clearly demonstrated the positive role of SBC for improved health outcomes among target populations.

SBC interventions complement and enhance improvements to health service delivery by addressing barriers to accessing these services and by enhancing interactions between health providers and clients. Findings from the Tulonge Afya midterm evaluation report https://pdf.usaid.gov/pdf_docs/PA00WRZ7.pdf show that the activity was successful in improving health seeking behaviors across the priority health areas, including, but not limited to, increased use of condoms, modern FP methods, HIV testing services, and insecticide treated bednets;

increased delivery in clinics; and increased antenatal care (ANC) visits.

Lessons learned from the mid-term evaluation point to the need for stronger linkages and coordination between SBC and service delivery interventions at community level. The gender, GBV, and youth-friendly services components should be focused to meet the persistent health needs of women and youth.

The contractor will implement a comprehensive package of evidence-based SBC interventions at the community level. Interventions must be appropriately tailored to the targeted communities and populations (i.e. by gender, age, etc.).

For example Tanzania’s Furaha Yangu campaign has been the primary platform to convey messages related to stigma and treatment literacy among the general population, with a focus on men and other priority populations. The Siteter eki campaign focuses on reaching youth on the same topics. Na weza focuses on women of reproductive potential, mothers, and men. The GOT is involved in campaign development and message approval and integrating consistent messages through other channels.

https://docs.google.com/document/d/1T1dtzT-h-WuENFhP6s58sTra4W4VZGOmz5jwSpdiKQg/edit%23heading=h.gjdgxs https://nam02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fpdf.usaid.gov%2Fpdf_docs%2FPA00WRZ7.pdf&data=02%7C01%7Cphewett%40popcouncil.org%7C6204b0ea155c44ae6e8408d845e28a74%7Cda295b63c8454fa2990b1ab42d54f2ca%7C1%7C0%7C637336186593356449&sdata=DWYrMe3tTmOmWJJnpjmtnoQz6rnG3BBoH7myMFATCXk%3D&reserved=0

The contractor will provide HIV/TB- social and behavior change technical assistance based on available or through rapid collection audience insights that identify drivers and barriers to desired behavioral outcomes. The required services include approaches that strengthen and focus community structures, community workers, the media, and community to deliver appropriate messaging on undetectable equals untransferable, harmful gender norms. The contractor will consider SBC approaches beyond communication including the use of nudges.

The required services will support providers to incorporate HIV testing messages, advocate for positive gender norms, and conduct GBV screening into testing and counselling sessions, and make appropriate referrals to safe space/shelters, support groups and legal services.

Expected Results: At a minimum, the Contractor must demonstrate improvement in the following indicators in each of the activity’s target health facilities/communities:

Mandated Result Performance Standard Improved ability of individuals to get early HIV tested, start ARV treatment and achieve viral suppression and increase access to PrEP for those high risk HIV negative individuals

1. TX_PVLS

2. TX_RET

3. PrEP_New

4. Recency

5. Proportion of people who recall hearing or seeing any

HTS messages within the last six months

6. Proportion of people who recall hearing or seeing specific HTS messages in the past 6 months

7. Proportion of people who believe the majority of their friends and community members currently get tested, start treatment early and achieve viral suppression

8. Proportion of people who believe that U= U (Undetectable=Untransmittable)

9. Increase in number of people using PrEP - PrEP_NEW

Sub IR 2.1 – Improved capacity, motivation and enabling environment related to health-seeking behavior

Accessing and using HIV and TB services is a challenge in Tanzania, especially for youth, due to insufficient knowledge, negative attitudes, and social and behavioral norms that stigmatize use of these services and do not encourage women and youth to take control of decision-making about their health. The negative attitudes and behaviors of health service providers further reinforce these barriers.

To address this concern, the Contractor must support social and behavior change (SBC) interventions at the health facility and community levels that build individuals’ capacity, motivation and urgency for service utilization, improve provider behaviors to enhance client satisfaction and the client-provider relationship, and boost habit-formation, adherence and maintenance of positive health behaviors. The Contractor must adopt innovative SBC approaches that are evidence based and address barriers and drivers for particular sub-populations. The interventions should lead to increased and continued use of HIV and TB services by clients, including treatment adherence to achieve viral suppression and timely follow up for other treatment needs.

following results in each of the activity’s target health facilities/communities:

Mandated Result Performance Standard Improved HIV treatment literacy and health seeking in target communities

10. TX_PVLS

11. TX_RET

12. Recency

13. SBCC message recall (disaggregated by HIV,FP,TB)

14. GEN_GBV

Sub IR 2.2 Increased community support for healthy behaviors

Community engagement is critical to improve and sustain the HIV treatment outcomes by creating a supportive social environment. The Contractor will implement gender transformative SBC interventions to address inequalities in service utilization, especially among youth. Given the important role men play in decision making and their low uptake of testing services, the Contractor will implement effective male engagement approaches.

At a minimum, the Contractor must demonstrate improvement in the following indicators in each of the activity’s target health facilities/communities:

Improved social norms for healthy behaviors

1. Increased number of PSNUs working with influential community leaders (FBO, CBO leaders) for community engagement

2. Increased number of PSNUs implementing community score cards to monitor quality of services

3. Increase in bi directional referral community-facility referral completion rate

Intermediate Result 3: Enhanced enabling environment for quality HIV/TB service provision

● Sub IR 3.1 Improved availability of quality strategies, policies and guidelines to support health service delivery

● Sub IR 3.2 – Increased engagement of communities and citizens for quality health service delivery

● Sub IR 3.3 - Increased engagement and use of systemwide reforms and governance structures that impact service provision following indicators in each of the activity’s target health facilities/communities:

Mandatory Result Performance Standard Enhanced enabling environment for quality HIV/TB service provision

1. Number of policy and guidelines updates (including FP/HIV/TB)

2. Number of data collection tools for integrated health services in use

3. Number of CSOs and private sector entities receiving USG support actively working to improve the quality of TB/HIV services delivery, including the use of quality data for decision-making

4. 70% of community structures that have mechanisms for meaningfully engaging community in implementing key health interventions

Sub IR 3.1 – Improved availability and operationalization of strategies, policies, and guidelines

Tanzania has in place a broad foundation of policies, guidelines and standard operating procedures (SOP) that inform HIV/TB programming. As most of these documents end in five years’ time, initiatives to update guidelines, SOPs and policy documents to reflect current scientific evidence available, will continue to be of paramount importance. To achieve this important milestone, the HIV/TB award will continue to support the GOT to update those documents that are critical to ensuring the availability of quality integrated HIV and TB services. Importantly, the Contractor will also ensure GOT and stakeholders operationalize the updated documents.

Expected Results: At a minimum, the Contractor must demonstrate improvement in the following indicators in each of the activity’s target health facilities/communities:

Mandatory Result Performance Standard Improved availability and operationalization of strategies, policies, and guidelines

1. Number of policy and guidelines updates (including FP/HIV)

2. Improved availability of data collection tools for integrated health services

3. Improved availability of quality assurance tools for integrated services

4. Number of CSOs and private sector entities receiving USG support actively working to improve the quality of TB/HIV services delivery, including the use of quality data for decision-making

5. % of community structures that have mechanisms for meaningfully engaging community in implementing key health

Sub IR 3.2 – Increased engagement of communities and citizens for quality health service delivery

Available evidence in the country shows community engagement is inadequate in HIV and TB programming. Active community engagement has been recognized as one of the key interventions for reaching and sustaining ensuring epidemic control.

This award will address these gaps by ensuring there are effective community engagement approaches, including strengthening existing community structures to optimize use of health services, including use of Community Health Workers (CHWs), and operationalization of tools to facilitate community and facilities collaboration to ensure quality improvement in HIV/TB care. These approaches will improve acceptability and care seeking practices among beneficiaries of integrated quality services in the served communities.

Expected Results: At a minimum, the Contractor must achieve the following results in each of the activity’s target health facilities/communities:

Increased engagement of communities and citizens for quality health service delivery

1. 70% of community structures that have mechanisms for meaningfully engaging community in implementing key health interventions

Sub IR 3.3 - Increased engagement and use of system-wide reforms and governance structures that impact service provision

The services required include support for evidence-based interventions and revision of policies that may hinder access to and uptake of services. The contractor will support the on-going equipping and retaining of community health care workers. Technical assistance will strengthen GoT responsiveness.

CSOs will be fully engaged in implementation of the community-led monitoring (CLM) activities under UNAIDS coordination. Findings from CLM will be discussed with GoT and recommendations for improvements related to client-centered HIV care and treatment reached in consensus.

Expected Results: At a minimum, the Contractor must demonstrate improvements in the following results in each of the activity’s target health facilities/communities.

Increased engagement and use of system-wide reforms and governance structures that impact service provision

1. Number of councils correctly implementing use of GOT systems epicor, GOTHOMIS etc

2. Number of Multi Sectoral AIDS committee functioning

3. Number of councils with community led monitoring systems

VI. MONITORING, EVALUATION, AND LEARNING (MEL) PLAN

Under the results-focused C3HP – HIV/TB Activity, the Contractor is required to create a Monitoring, Evaluation, and Learning (MEL) Plan detailing how it will ensure robust monitoring of all activities, including capacity-building. Data quality is critical, and the Contractor must use systems that ensure quality data within short timeframes and be prepared for regular data quality assessments. Any experimental and/or quasi-experimental research designs must be clearly reflected in the Contractor’s MEL plan. The contractor is also expected to integrate Developmental evaluation activities within the project, develop DE plan that include intervention areas to be monitored and evaluated for real time program improvement throughout the life of the project.

The MEL Plan will feed into USAID/Tanzania’s CDCS Performance Management Plan and incorporate indicators currently collected through the Agency’s annual Performance Plan and Report. To ensure data-driven decision-making, the Contractor will track and analyze progress against activity targets and also consider other data collected through GOT and USG monitoring and evaluation systems and findings from periodic and national population and facility and community-based surveys conducted by other entities. The USG will continue to compile and analyze data concerning the achievements and performance of all of its HIV/TB implementing partners as well as the data from other donor-funded programs working in these health areas.

USAID/Tanzania is required to report annually to USAID/Washington and PEPFAR on the following standard indicators, and the Contractor must inform this reporting:

1. HTS_TST

2. HTS_TST_POS

3. HTS_Index

4. TX_CURR

5. TX_PVLS

6. SC_ARVDISP

7. TB_PREV

8. TB_STAT

9. TB_ART

10. PrEP_CURR

11. PrEP_NEW

12. FP INT_SITE

13. Number of clients accepting a modern family planning method (Disaggregated by Sex, Age (10-14, 15-19, 20-24, or 25+), Contraceptive method, Type of user (new or continuing) and Type of service (routine or outreach)

14. Couple years protection provided with USG support (disaggregated by contraceptive type and geographic location)

15. HRH_CURR

16. HRH_Staff (disaggregated by facility and community staff)

17. Number of clients treated for active TB.

18. Number of TB clients cured.

19. Number of MDR TB patients started second line Ant TB medicines

20. Number of MDR TB patients cured

The Contractor must review activity performance regularly in face-to-face meetings with the Contract Officer’s Representative (COR) on a schedule to be agreed upon by the Chief of Party and the COR.

USAID/Tanzania anticipates an external performance evaluation at least once during the life of the activity, in approximately the third year of implementation. USAID/Tanzania my use a Mission-wide third-party evaluation contractor to conduct this evaluation and/or an independent evaluation. The Contractor must collaborate fully with USAID/Tanzania’s third-party evaluation contractor.

VII CROSS - CUTTING ELEMENTS

Gender and Women’s Empowerment In 2012, USAID launched its Gender Equality and Female Empowerment Policy which focuses on and gives coherence to the various efforts towards gender integration and provides guidelines for roles and responsibilities within the Agency, as well as for the programming it supports. The three main achievements that USAID wants to accomplish through this policy are reaching gender equality, reducing gender-based violence, and empowering women and girls. The goal of the policy is that all new programming will strive toward these results.

Gender impacts all development outcomes for women and men; to be most effective, health programs must take this into consideration at all stages of programming – planning, implementation, monitoring, and evaluation – and at all points along the illness/health continuum.

For HIV, TB and FP programming, it is critical that risk factors, exposure to disease, knowledge, access to services, diagnosis and treatment, and support be considered.

In Tanzania, men have higher rates of TB than women. Men are commonly thought to be more at risk for TB due to both physical and behavioral reasons. However, in some places, women have high rates of TB, likely due to restricted access to health services. Additionally, women with HIV are at high risk for TB, and in some age groups women’s HIV prevalence is twice that of men.

Research has also shown that men, on average, delay seeking care more than women and have lower treatment success rates for TB, and lower knowledge of their HIV status.

For FP, nearly all women in Tanzania are aware of contraception, but only 32 percent of married women use a modern method. The power dynamics between men and women profoundly influence women’s health-seeking behavior regarding contraceptive use. Women often are unable to make decisions on their own regarding their health and well-being. For example, in most traditional households, men control decisions regarding the use of contraception and access to health services.

Men control women’s access to health services, because they are the primary household decision-makers and control the majority of household economic resources. Gender-based violence is also widespread in Tanzania, and it limits women and girls’ ability to negotiate safer sexual practices, access to FP/RH services, and disclose any health issue that they may be experiencing.

Gender equality and women’s empowerment are essential for achieving the results of the HIV/TB Activity. To that end, the offeror should implement interventions that include the identification and correction of gender-based inequities in HIV/TB and FP service delivery. These should address the underlying reasons for gender-based differences and apply gender-transformative or gender-sensitive approaches when designing, implementing, monitoring, and evaluating their work. All of the offeror’s interventions should assert and uphold the right of all individuals to quality health services. Moreover, the offeror of the HIV/TB Activity will be expected to:

● Have a comprehensive understanding of gender relations, division of labor and decision makers, and who has access to and control over resources with the aim of enhancing service uptake

● Use participatory processes and engage a wide range of female and male stakeholders to ensure the delivery of quality HIV and TB and FP services at the facility level

● Gain an understanding of women’s and men’s health needs and strategic interests in order to identify opportunities to support their use of health services

● Identify and address barriers to women’s and men’s participation in HIV and TB and FP services

● Consider the differential impact of interventions on women and men and identify consequences to be addressed.

Youth Inclusion The USAID Youth in Development Policy aims to strengthen youth programming, participation, and partnership in support of Agency development objectives and to mainstream and integrate youth issues and engage young people across Agency initiatives and operations. In Tanzania, youth empowerment and inclusion are critical cross-cutting issues throughout the Mission’s CDCS results framework, and they are central tenets of the CHSD PAD and all resulting health activities.

The offeror for the HIV/TB Activity is expected to reach youth by: (1) ensuring their health needs are met, particularly as it relates to HIV/TB and Family Planning; (2) preventing and responding to violence, exploitation, abuse, and neglect and ensuring young people are safe and receive care;

(3) building youth competencies and skills to stay healthy in order to become informed and…