RFI_-_Liberia_Community_Health_Activity.pdf

ACTIVITY TITLE

The name of the anticipated activity is Community Health Activity.

PURPOSE FOR THE RFI

The purpose of this Request for Information (RFI) is to solicit industry feedback for USAID’s future investments related to community health and water, sanitation and hygiene (WASH) services. USAID’s theory of change is that through a well-coordinated and a fully functional national community health program, expanded quality health/WASH services and increased uptake of key high-impact interventions such as family planning, immunization services for children under one, maternal, neonatal and child health, including prevention and treatment of malaria will improve the health status of rural and disadvantaged communities.

USAID anticipates 1-2 funding opportunities in the area of community health and currently envisions one focused on the expansion of the community health assistant (CHA) program and the second, complementary piece on community engagement, community and household-level behavior change that strengthens the impact of the CHA and facility-level investments, and WASH services.

BACKGROUND/CONTEXT

Since the end of Liberia’s prolonged civil war, Liberians have been experiencing steady improvements in their health status.1 Despite this progress, large disparities in access to care and health outcomes still exist between urban and rural populations with approximately 29% of Liberians, and 60% of rural Liberians, living more than one-hour walk from the nearest health facility.2 Community-based services are vital to the health and wellbeing of these communities.

The recent Ebola epidemic in Liberia and across West Africa highlighted the critical role that communities play in addressing their own health needs and changing their own health behaviors across a wide range of health issues to stay healthy as well as prevent and respond to epidemics. Challenges in accessing quality health care limit the uptake of key high-impact interventions such as family planning, immunization services for children under one, and the prevention and treatment of malaria.

In the WASH sector, Liberia underscores minimal progress in terms of increasing access for water and sanitation services. According to the latest Joint WHO/ UNICEF Monitoring Program (JMP), access to safe drinking water is 76%, showing an increase of 19 percent from 1995 - 2015. By the end of 2015, only 17 percent of the population had access to improved sanitation services, against a target of 52 percent. Despite political commitments to advance the WASH

For example, the under-five child mortality rate has decreased from 220 deaths/1,000 live births in 1986 to 110 deaths/1,000 live births in 2007, with 2013 Liberian Demographic and Health Survey (LDHS) results showing further improvements to 94 deaths/1,000 live births. With regard to reproductive health (RH) services, national facility-based delivery percentages increased from 37% to 56% between 2007 and 2013.

Liberia Demographic Health Survey (LDHS) 2013.

agenda, financial spending in the sector has not kept pace with even modest budget allocations due to diffuse responsibility for WASH across several government ministries or institutions.

According to the Joint Sector review report (2018), public spending for WASH services remain at less than one (1) percent of the total budget. This inadequate financing, coupled with other sector problems such as inadequate number of staff, dysfunctional and badly constituted regulatory body, have resulted in minimal progress, particularly in the rural areas.

Government of Liberia’s National Community Health Assistants Program:

The MOH has prioritized community health services (CHS) as an effective and efficient strategy to improve access to healthcare. With support from donors and partners, the Ministry’s Community Health Services Division (CHSD) revised its policy on community health services and launched the national community health assistants (NCHA) program in 2016, instituting a new cadre of trained, incentivized and equipped Community Health Assistants (CHAs). The Revised National Community Health Services Policy addresses all issues relating to community health services and systems raised in the National Health Plan and the Investment Plan to facilitate the attainment of the goals outlined in the Essential Package of Health Services (EPHS)3. It draws upon the relevant sections of the National Health Promotion Policy and Strategic Plan, the Roadmap for Accelerating the Reduction of Maternal and Newborn Morbidity and Mortality in Liberia as well other Government of Liberia (GOL) policies related to community health. The overall goal of the Revised National Community Health Services Policy is to extend the reach of the country’s primary health care system via an integrated and standardized national community health model that can provide a package of essential life-saving primary health care services and epidemic surveillance within communities and to households on an equitable basis. A key feature of this revised policy is the institution of a new cadre of CHAs, who are selected from and serve communities, located more than a one-hour walk (more than 5km) from the nearest health facility. Despite gains in the percent of clients with access to health facilities within a 5km radius nationally, considerable variations still exist between counties and districts, particularly with regard to coverage and scope of service delivery.

Incentive payments to CHAs and Community Health Services Supervisors (CHSS) continue to be a challenge to the sustainability of the program. At the moment all CHAs and CHSS’ are being paid by donors through implementing partners or County Health Teams (CHTs), resulting in continued reliance on donors. Additionally, adopting healthy behaviors remains a critical barrier to improved health outcomes. While the MOH National Health Communication Strategy has been developed, it has not been disseminated to all parts of the country.

Since the launch of the NCHA program, the MOH has been providing access to health services for populations in hard-to-reach communities in 66 of the 88 health districts of the country. The NCHA program builds on lessons from demonstration projects in Liberia and community health experiences in other countries. The CHA Program has scaled rapidly since its launch in 2016, reaching ~70% coverage of total remote population (1.05 million total)4.

Currently, there are 3,016 CHAs and 350 CHSSs deployed (as of June 2018) across targeted districts in 14 of Liberia’s counties. With support from donors and partners, the MOH also developed a standardized curriculum to be used to train CHAs across the country. Supervision and reporting tools have also been developed and are being used. One key achievement of the

Revised National Community Health Services Policy addresses

NCHA Dashboard of June 2018 community health delivery system is the integration of community-based health information system into the DHIS2 platform, thus improving visibility and accountability of community-based health programs. Challenges such as commodity stock-outs, gaps in supervision and reporting, incentive payments to CHAs and CHSS by donors and attrition continue to hamper the effectiveness of the NCHA Program. This activity will explore the possibilities of establishing “community health funds” by mobilizing communities to make regular voluntary contributions, mobilize local labor and promote community motivation for health activities.

Integrated Approach to Maternal and Child Healthcare, and Family Planning The most recent Malaria Indicator Survey (MIS) showed great gains in contraception use with an estimated modern prevalence rate (mCPR) of 30.7 percent, placing Liberia ahead of its original FP2020 goal of 20 percent by 2021 (MIS 2016). Data from MIS 2016 estimated that the mCPR grew at a rate of 3.4 percentage points a year between 2013 and 2016, and in the past nine years, it grew by 2.1 percentage points every year. Despite this progress, meeting the contraceptive needs of young people is of paramount importance.

According to the 2008 Census, 32.8 percent of the population consists of adolescents and youth (10-24 years). The median age for child-bearing for Liberians is 16.9 years, well below the age of 20 years recommended by the WHO. Further compared to all other age groups, adolescents have the highest total demand for contraceptives (92.4 percent), and the highest unmet need (59.5 percent) across all age groups. However, low contraceptive use among this age group, and other predisposing factors, are key contributors to the high teenage pregnancy observed in Liberia ─ 31 percent of young people between the ages of 15-19 years have started childbearing.5

Malaria Malaria is endemic in Liberia and transmission occurs year-round within all geographic areas.

Thus, the entire population of approximately 4.8 million is constantly at risk. Children under the age of five years and pregnant women are the most affected groups. The 2013 Health Facility Survey (HFS) found that malaria is the leading cause of morbidity and mortality, accounting for 42% of all outpatient consultations and 44% of all inpatient deaths among children under the age of five years. The 2016 MIS showed a malaria prevalence of 45% among children age 6-59 months, with regional variations from 12% in Greater Monrovia to 69% in South Eastern B. A combination of unmet maternal child health services, family planning needs, and malaria exposure presents even more dire health issues. Compared with non-pregnant women, pregnant women have a higher probability of suffering from severe anemia and complications such as cerebral malaria, respiratory distress and death. Their pregnancies are at risk of miscarriage, preterm birth, stillbirth as well as low birth weight and infant mortality.

Nutrition Improved nutrition can help accelerate health, social, and economic benefits. Liberia has made some progress towards reducing stunting and improving exclusive breastfeeding (EBF) rates, yet malnutrition continues to affect nearly one-third of all children under five and policies that help ensure the optimal feeding of infants and young children are lacking. Early initiation of breastfeeding within the first hour of life is 61% while EBF of infants under 6 months is at 51%.6 Additionally, significant number of infants are still sub-optimally breastfed. Among children aged 6 -23 months, only 23 percent met minimum dietary diversity standards, while 77 percent did not

Liberia Draft Costed Implementation Plan (CIP) for Family Planning 2018

Comprehensive Food Security and Nutrition Survey (CFSNS 2018) meet the minimum dietary diversity. In addition, 89 percent of Liberian children are fed mainly rice and lack sufficient nutrients, especially vitamins and minerals. Some 59 percent of children under 3 are anaemic (LNMS, 2011)7. Stunting rate remains relatively high at 32% according to DHS 2013 and spatially distributed across the country with no significant differences across counties. MOH nutrition priority is focused on reducing stunting and is aimed at addressing bottlenecks and barriers around key broad areas including supply, enabling environment and demand. Through the supply side, the MOH intends to integrate direct nutrition interventions (DNI) into routine services to address the immediate causes of malnutrition; through enabling environment, the MOH has reviewed and updated the nutrition policy and a set list of standard nutrition indicators have been included in the HMIS with stunting reduction being featured in the GOL’s Pro-Poor Agenda for Prosperity and Development (PAPD). The MOH intends to create demand by raising awareness on uptake of nutrition services across the country.

Drinking Water Supply and Community Led Total Sanitation Given the gaps and challenges in WASH in rural areas, the activity must address both the issue of sustainable access for drinking (safely managed) water supply at the county level and at the same time develop/expand the implementation capacity of the Ministry of Public Works. The challenges in the rural water sector has been the functionality and sustainability of rural water points, ranging from shallow wells unable to supply the desired quality and quantity of water as well as the technical capacity related to operation and management. Specific activities in the water sector need to follow a two pronged approach of increasing availability and sustainable management of safe water and sanitation for the under-served and most vulnerable, in alignment with U.S. national security and foreign policy objectives; and technical assistance to create a management capacity of stakeholders; namely the MPW; County WASH office and the newly established National Water Sanitation and Hygiene Commission (NWASHC), reorienting it to play a critical regulatory role, as envisaged in the original Liberia’s WASH strategic document.

A 2017 midterm evaluation of the current community health activity discovered that in Community Led Total Sanitation (CLTS) communities, including those that have become open defecation free (ODF), the sanitation infrastructure comprises locally constructed latrines, showers, and hand-washing stations. This infrastructure is to be maintained by the households that built and own them, in accordance with the CLTS approach of local ownership. In a few communities, however, latrines and shower stalls had collapsed, reportedly due to poor construction with weak materials, such as weak sticks covering latrine pits. Compounding the infrastructure decay, many households in these communities reside away from home, to be close to their farms, during planting and harvesting seasons. While residing near their farms, household members do not usually construct a second set of latrines and revert to open defecation in the bush. When household latrines become unusable from lack of maintenance, or when the latrine pits become full because they are too small for the household size, community members simply continue defecation in the bush as they had practiced on their farms. These factors need further exploration, and there may be other mechanisms and behaviors that lead to ODF communities relapsing to open defecation. Through this activity, USAID will work with communities to resolve the emerging issue of relapsed ODF communities, and involve GOL and CLTS partners in refining the model to address the factors that lead to relapse to open defecation.

Liberia National Micronutrient Survey, 2011

OVERALL OBJECTIVE(S) OF THE COMMUNITY HEALTH ACTIVITY

The purpose of USAID’s investments in community health and WASH is to support a robust community based program including the scale up of the National CHA Program (NCHAP)for the delivery of efficient, responsive, equitable, and quality health services for improved access and health status for Liberians.

There are four (4) objectives:

1. Support the expansion of the National CHA program (both geographic and population coverage) in underserved districts and communities including remote areas;

2. Increased access to improved quality of health services through trained, supervised and motivated CHAs;

3. Enhance health facilities and communities’ capacity to plan, manage, and monitor a comprehensive delivery of health services; through engagement with community and traditional leaders to improve health behaviors

4. Increased access to basic water and sanitation services in households, improved management of fecal waste, and promotion of key hygiene behaviors.

OBJECTIVES AND ANTICIPATED OUTCOMES

Obj. 1: Support the expansion of the National CHA program (both geographic and population coverage) in underserved districts and communities including remote areas;

Anticipated outcomes:

1. Increased coverage of CHAs per population ratio (40-60 households-up to 350 Population)

2. Improved health access to rural Liberians

3. Reduced dropout rates for CHAs

4. Sustainable CHA incentive scheme (for services rendered) in place

Obj. 2: Increased access to improved quality of health services through trained, supervised and motivated CHAs;

1. Improved supportive supervision, training in new approaches, and health messaging tools in place for CHAs.

2. Increased number/percentage of CHAs can correctly assess, diagnose and treat for iCCM, (testing, identifying signs and symptoms for referral for malaria, diarrhea, and pneumonia).

3. Improved quality across the CHA program to contribute to change in health indicators such as reduction in diarrhea and malaria incidences, malaria test rates, underweight children and increased uptake of modern contraceptives by women of reproductive age.

4. Improved coordination, planning and integration of Social Behavior Change (SBC) for access to quality services.

Obj. 3: Enhance health facilities and communities’ capacity to plan, manage, and monitor a comprehensive delivery of health services through engagement with community and traditional to improve health behaviors

1. Government ownership of CHA program expanded and adopted at health facility and community level.

2. Health facilities and communities’ capacity strengthened to support, own and sustain health interventions.

3. Community engagement and increased community involvement and full participation throughout implementation strengthened through harnessed local community solutions.

4. Functional community management structure for CHA program established

5. Improved availability of commodities for CHA program

6. Health facility to community level supply chain structure and reporting system functional to ensure accountability and access

Obj. 4: Increased access to basic water and sanitation services in households, improved management of fecal waste, and promotion of key hygiene behaviors

1. Sustainable access for water and sanitation services.

2. County/district wide coverage of sustainable sanitation services attained.

3. County /district wide triggering of communities and achieving ODF status.

4. Market-based sanitation approach scaled up in cities within the county(ies) and communities move up the sanitation ladder (eg. move from basic to improved sanitation).

5. Mini water supply systems promoted, constructed and operated with solar power source.

6. Rural water sector governance (county water offices, Ministry of Public works and the newly established regulatory body) strengthened.

ASSUMPTIONS

It is assumed that the GOL will continue to prioritize the scale up of the NCHAP and provide leadership in addressing the challenges and gaps identified in the delivery of community health services, at both central and county levels, that will eventually contribute to the achievement of the goal of the Resilient Health Plan 2015 – 2021 and contribute to the Ministry of Health’s Pro- Poor Agenda Priorities. Additionally, it is assumed that the GOL will support the enabling environment necessary for program implementation and improvement in the performance of CHAs resulting in an improvement of the quality of services provided to the population. GoL and communities will be able and willing to mobilize domestic resources to sustain the community based programs and commodities available and supplied to CHAs.

PROPOSED INTERVENTIONS

Interventions are anticipated to be integrated. However, USAID welcomes suggestions and ideas around the possibility of splitting interventions under two separate activities, or maintaining one activity. Specifically, one intervention focuses on the support and scale up of the National Community Health Assistant program including incentive payments to CHAs and CHSSs, and the second activity focuses on community engagement, Social Behavior Change, Water Sanitation and Hygiene (WASH) service delivery including innovations around mini water systems for sustainability and adopting key hygiene behaviors; technical assistance to county WASH teams and MPW. The following services are expected to be delivered:

● Malaria Prevention and Treatment

● Water supply, sanitation and hygiene services

● Nurturing care for infant and young child including nutrition and early childhood development

● Family planning

● Working with community/traditional leaders

● Integrated community management of childhood illness, with a focus on malaria, diarrhea, and pneumonia.

● Advocacy and SBC.

ILLUSTRATIVE INDICATORS (NOT A COMPLETE LIST)

● Number of CHAs trained in management of childhood illnesses and nutrition

● Treatment rates for malaria, diarrhea & pneumonia

● Proportion of fever cases tested for malaria at community level

● Proportion of malaria confirmed uncomplicated cases treated with ACTs

● The proportion of communities served that know the correct treatment for uncomplicated malaria

● # of women 15-49 using modern contraceptive method

● # of malnutrition screenings of children under-five conducted using MUAC

● Number of people receiving improved service quality from an existing basic drinking or safely managed water service as a result of USG assistance

● Number of communities verified as open defecation free (ODF) as a result of USG assistance

● Number of people gaining access to a basic sanitation service as a result of USG assistance

● % of population with basic drinking water facilities

● % of population with basic sanitation facilities

● Percent of households in target areas practicing correct use of recommended household water treatment technologies

● Percentage of households with soap and water at a handwashing station commonly used by family members

● % of population with handwashing facilities

● proportion of pregnant women who attend ANC visits

● proportion of pregnant women who sleep under an ITN

● Proportion of caretakers of children under five who perceive prompt treatment seeking to be the norm in their community.

● Proportion of people who recall hearing or seeing malaria or family planning message in the last 6 months

● Proportion of CHAs who perform an RDT for malaria correctly

● Proportion of cases (malaria, diarrhea & pneumonia) treated according to protocol

STRATEGIC/PARTICULAR QUESTIONS FOR FEEDBACK.

Community engagement/integration

1. What are the options for focusing integration around the One Health (animal and human health) approach?

2. What components of early childhood development can be integrated into community based programs?

3. How can traditional leaders be engaged?

WASH/SBC

1. What are the factors that are leading to ODF communities reverting to OD; how do they vary according to context, and how do they interact?

2. What are the factors that affect sustained behavior change?

Capacity building/sustainability

1. What capacity building approaches/models would be appropriate to support MOH units (central and CHT) for sustainability of community based programs?

2. Are there specific gap areas that could be prioritized?