RFP-SOL-612-16-000001_ONSE.pdf

Organized Network of Services for Everyone’s (ONSE) Health Request for Proposals (RFP) Number: SOL-612-16-000001

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS:

B.1. SERVICES

The purpose of contract is for the Contractor to implement the Organized Network of Services for Everyone’s (ONSE) Health activity in accordance with the Scope of Work in Section C.

B.2. CONTRACT TYPE

This is a Cost-Plus-Fixed-Fee (CPFF) completion-type contract consistent with Federal Acquisition Regulation 16.306(d)(1). For the consideration set forth in this Section B, the Contractor must provide the outputs as described in Section C and the deliverables as described in Section F in accordance with the performance standards specified in Section F.

B.3 ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT

(a) The estimated cost for the performance of work required hereunder, exclusive of fixed fee is [will be completed upon award]. The fixed fee is [will be completed upon award].

The estimated cost plus fixed fee is [will be completed upon award]. Cost must be limited to reasonable, allocable, and allowable costs determined in accordance with Federal Acquisition Regulation (FAR) 52.216-7.

(b) Fixed Fee Payment: At the time of each payment of allowable costs to the Contractor, the USAID paying office ordinarily pays the Contractor a percentage of the fixed fee that directly corresponds to the percentage of allowable costs being paid. Two exceptions to paying fixed fee in this manner apply:

(1) If the Contracting Officer determines that this method results in paying a disproportionately higher ratio of fixed fee than the percentage of work the Contractor has completed, then the Contracting Officer may suspend further payment of any fixed fee until the Contractor has made sufficient progress to justify further payment, up to the agreed percentage.

(2) Because the clauses entitled "Allowable Cost and Payment" (FAR 52.216-7) and "Fixed Fee" (FAR 52.216-8) are incorporated into this contract, the terms and conditions of these clauses apply after total payments of fixed fee reach eighty five percent (85%) of the total fixed fee.

(c) Within the estimated cost plus fixed fee specified in paragraph (a) above, the amount currently obligated and available for reimbursement of allowable costs incurred by the Contractor (and payment of fee), is [will be completed upon award]. The Contractor will not exceed the aforesaid obligated amount.

B.4 BUDGET [will be completed upon award]

B.5 INDIRECT COSTS

The Contractor is authorized to recover applicable indirect costs, if it is part of the contractor's usual accounting procedures, consistent with FAR Part 31, and Negotiated Indirect Cost Rate Agreement (NICRA).

Pending establishment of revised provisional or final indirect cost rates, allowable indirect costs will be reimbursed on the basis of the following negotiated provisional or predetermined rates and the appropriate bases as below:

[To be inserted at the time of award]

B.6 PAYMENT

The paying office is USAID/Malawi as indicated in section G.4; payment processing will be in accordance with section G.3 of this Contract.

B.7 COST REIMBURSABLE

The U.S. dollar costs allowable must be limited to reasonable, allocable and necessary costs determined in accordance with FAR 52.216-7, Allowable Cost and Payment, FAR 52.216-8, Fixed Fee, if applicable, and AIDAR 752.7003, Documentation for Payment.”

No: CLIN Item Description Year 1 Year 2 Year 3 Year 4 Year 5 Total Amount

001 Access to priority health services increased

002 Quality of priority health services improved

003 Performance of health systems strengthened

004 Demand for quality priority health services increased

Total Direct Costs Per Year Total Indirect Costs Per Year Fixed Fee Total Cost Plus Fixed Fee

B.8 PAYMENT OF FIXED FEE / FIXED FEE PAYMENT SCHEDULE

Payment of the fixed fee will be made as follows. The Contractor’s fixed fee is tied to the accomplishment of performance objectives and deliverables or outputs described in Section F that are specified in the fixed fee payment schedule below. The contractor will be paid the amount of fee specified for each denoted performance objective, deliverable or output set forth in the table below upon acceptance by the Contracting Officer’s Representative (COR). Because the clauses entitled "Allowable Cost and Payment" (FAR 52.216-7) and "Fixed Fee" (FAR 52.216-8) are incorporated into this contract, the terms and conditions of these clauses apply after total payments of fixed fee reach eighty five percent (85%) of the total fixed fee.

[Payment amounts will be proposed by Offerors and negotiated]

No. Performance Objective

Deliverable / Output Reference Section

Amount Year

Year

Year

Year

Year 5

Activity Deliverable 1 Annual Workplan F.5(a).1 2 Five Year Implementation

Plan F.5(a).2

3 Grants Under Contracts Manual

F.5(a).3

4 Activity Monitoring and Performance Plan

F.5(a).4

5 Monthly Update F.5(a).5 6 Quarterly Financial

Progress Report F.5(a).6

7 Consultant Activity Report F.5(a).7 8 Annual Activity Report F.5(a).8 Performance Objective/Output CLIN 001 Access to priority health services increased 1-1. Couple Years Protection C.9. IRI 1 1-2. Percent of population using an improved drinking water source

C.9. IRI 1

1-3. Percent of health facilities with established capacity to manage acute under-nutrition

C.9. IRI 1

1-4. Percent of population using an improved sanitation facility

C.9. IRI 1

1.1-1. Percent of USG-supported facilities that provide appropriate life-saving maternity care (This will be defined as seven signal

C.9. IRI 1

functions for BEmONC)

1.1-2. Percent of USG-supported facilities that provide appropriate life-saving maternity care (This will be defined as nine signal functions for CEmONC)

C.9. IRI 1

1.1-3. Percent of non-public health facilities (including CHAM, NGO and private-for-profit institutions) supported by USG to provide priority health areas

C.9. IRI 1

1.2-1. Percent of USG-supported health facilities certified in the provision of Youth-Friendly Health Service

C.9. IRI 1

1.2-2. Percent of health facilities offering priority health services (assessed separately for each service)

C.9. IRI 1

1.2-2.a. Child health and nutrition C.9. IRI 1 1.2-2.b. Family planning C.9. IRI 1 1.2-2.c. Maternal and newborn health

1.2-2.d. Malaria C.9. IRI 1 1.2-3. Percent of health service delivery points offering community based health services

C.9. IRI 1

1.2-3.a.Maternal newborn, child health, FP and nutrition

C.9. IRI 1

1.2-3.b. Percent of USG-supported communities establishing an emergency transport system for pregnant women within the reporting period

C.9. IRI 1

1.3-1. Percent of health facilities overstocked with tracer malaria commodities (LA1, LA2, LA3, LA4)

C.9. IRI 1

1.3-2. Percent of health facilities that have equipment considered basic to quality client services

C.9. IRI 1

available in the general outpatient service area

CLIN 002 Quality of priority health services improved 2-1. Percent of health facilities conducting postnatal health checks to >=95% of newborns within two days of birth

C.9. IRI 2

2-2. Percent of births receiving at least 4 antenatal care (ANC) visits during pregnancy

C.9. IRI 2

2-4. Percent of suspected malaria cases tested by either microscopy or rapid diagnostic test

C.9. IRI 2

2-5. Percent of pregnant women who received three or more doses of IPTp during ANC.

C.9. IRI 2

2-6. Percent of confirmed malaria cases receiving first line anti-malarial medication

C.9. IRI 2

2-6. Percent of health facilitates that maintain international SPHERE standards for the treatment of severe acute malnutrition

C.9. IRI 2

2.1-1. Percent of USG-supported health facilities achieving >= 80% of performance and quality standards for the priority health areas

C.9. IRI 2

2.2-1. Percent of USG-supported health facilities implementing quality assurance and quality improvement

C.9. IRI 2

CLIN 003 Performance of health systems strengthened 3-1. Percent of clients satisfied with availability and quality of services, disaggregated by health facilities and community clinics

C.9. IRI 3

3-2. Percent of health facilities with improved performance compared to previous year according to integrated supportive supervision checklist

C.9. IRI 3

3.1-1. Percentage of health facilities supervised using complete integrated supportive supervision tool and completing follow-up actions

C.9. IRI 3

3.1-2. Number of cost centers (districts and central hospitals) completely and accurately updating and utilizing iHRIS data

C.9. IRI 3

3.2-1. Number of districts that revise DIP activities or budgets based on feedback from progress reviews or from users/beneficiaries and the bodies that represent them

C.9. IRI 3

3.2-2. USAID and GOM priority health sector policies, strategies, and/or guidelines developed or updated and implemented in line with Activity workplan

C.9. IRI 3

3.3-1. Percent of health facilities submitting timely, quality DHISII and LMIS data in line with national standards

C.9. IRI 3

3.3-2. Evidence-based decisions made and actions taken using data sources supported by USAID assistance

C.9. IRI 3

CLIN 004 Demand for quality priority health services increased 4-1. Percent of population reporting unmet need for the priority health services

C.9. IRI 4

4.1-1. Percent of pregnant women who initiate ANC visits in the first trimester

C.9. IRI 4

4.1-2. Percent of children under age 5 with fever in the last two weeks for whom advice was sought from a health facility or provider

C.9. IRI 4

4.2-1. Percent of health facilities with functional health center advisory committees

C.9. IRI 4

4.2-2. Percent of Communities with functional Community

C.9. IRI 4

Action Groups

Section C.10.1 Integration

Number of integration interventions completed in collaboration with USAID/Malawi partners or development partners in accordance with the criteria identified in Section C.10.1

C.10.1

B.9 MULTI-YEAR CONTRACT

This contract is considered non-severable, and is therefore a multi-year contract as defined in FAR 17.103. Therefore, this contract is subject to the requirements of FAR 17.106.

Cancellation Dates:

Contract Year Date Amount Contract Year 2: $1,800,000 Contract Year 3: $2,000,000 Contract Year 4: $1,600,000 Contract Year 5: $1,400,000

[Note: Amounts are estimates to be negotiated with the Offerors]

Cancellation Ceiling:

This is a cost reimbursement completion-type contract where the Contractor is authorized to be reimbursed for all costs which are allowable in accordance with FAR 52.216- 7, “Allowable Costs and Payment”. Therefore, the Contractor will not incur any costs which would have been amortized over the life of the contract should the contract be cancelled in accordance with FAR 52.217-2. The cancellation ceiling for each cancellation date is indicated above.

[END OF SECTION B]

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK:

Title of Activity: Organized Network of Services for Everyone’s (ONSE) Health--referred to as ONSE Athanzi —which translates as “All Healthy.” For the remainder of the Statement of Work, ONSE Athanzi will be referred to as “the Activity.”

C.1 INTRODUCTION

The purpose of the activity is to support Government of Malawi (GoM) efforts to reduce maternal, newborn, and child mortality through improved access to maternal, neonatal, and child health including nutrition (MNCH), family planning/reproductive health (FP/RH), malaria, and water, sanitation and hygiene (WASH) services; improved quality of these four priority health services; strengthened district health systems in support of MNCH, FP/RH, malaria, and WASH; and increased community demand for these priority services.1

ONSE Athanzi is critical to achievement of the U.S. Agency for International Development (USAID)/Malawi Country Development Cooperation Strategy for 2013-2018 (CDCS)2 and its Development Objective 1 (DO 1): Social development improved; as well as the USAID Health Office Integrated Health Project (IHP) objective: Health status of Malawians in targeted districts improved. The Activity will be USAID’s primary mechanism for engagement in Malawi’s health sector at the district, facility, and community levels; will contribute to achieving USAID Ending Preventable Child and Maternal Death (EPCMD) goals; and will increase the modern contraceptive rate.

USAID/Malawi requires the Contractor to provide technical assistance and operational support to the GoM to improve the health of Malawians. The focus is primarily at district, facility, and community level, but includes targeted assistance at central and zonal levels in key areas that impact service delivery on the ground. Health facilities at all levels must be supported, including health centers, rural hospitals, district hospitals, and central hospitals. Over the last two decades, Malawi has achieved dramatic gains in most health indicators by focusing on the improved delivery of essential health services.3 It is one of few sub-Saharan African countries to have achieved Millennium Development Goal (MDG) 4 for child survival ahead of the target year of 2015. The country reduced maternal mortality by 53 percent between 1990 and 2013,4 and increased the contraceptive prevalence rate for married women from 7.4 percent in 1992 to 42 percent in 20105, and 58.6 percent according to the 2014 MDG Endline Survey. In addition, the human immunodeficiency virus (HIV) prevalence among 15-49 year old men and women declined from 12 percent in 2004 to 10.6 percent in 2010.6 Critically, the annual number of new HIV infections declined from 89,000 in 2004 to 42,000 in 2014.

These broad gains, however, mask problematic realities in the health system that must be addressed if the advances of the past two decades are to continue. With a total fertility rate of 5,7 Malawi’s population is forecast to triple to 40 million by 2040. Such growth has the potential to derail development gains made to date. Unmet needs of married women 15-49 years old for family planning services (19.4 percent) are very high, with acute needs among young people.8 Even with the gains in child health, almost one-half (42.4 percent) of children are stunted.9 Malawi is a high-burden malaria country with an estimated incidence rate of 332/1,000 population, and approximately 6 million episodes of malaria per year.10 Nearly half of the established positions in the health sector are vacant, and a perpetual shortage of qualified health workers persists.11 Such tremendous health challenges, combined with constrained economic resources and difficulties reaching marginalized populations like persons with disabilities (PwD), women and youth, place an unmanageable burden on the health system.

The Activity continues the efforts of the Support for Service Delivery Integration (SSDI) 2011- 2016 activity, SSDI-Services. By programming district level HSS and community mobilization programs, it also partially continues the effort of two other SSDI components:

SSDI-Systems and SSDI-Communications. The Activity is USAID/Malawi’s flagship health mechanism to improve the health status of Malawians, and will operate primarily at the district, facility, and community levels.

The purpose of this Activity is to reduce maternal, newborn, and child morbidity and mortality. To accomplish this, the Contractor is required to execute interventions in HSS and the four core technical areas –FP/RH, MNCH, malaria, and WASH - that contribute to the achievement of the four interrelated and interdependent intermediate results (IRs):

IR.1 Access to priority health services increased IR.2 Quality of priority health services improved IR.3 Performance of health systems strengthened IR.4 Demand for priority health services increased

C.2 BACKGROUND

C.2.1 GoM Public Sector Reforms The GoM is engaged in major public sector reforms that will affect all sectors, including the health and the water and sanitation sectors. In particular, the 1998 Local Government Act and National Decentralization Policy (NDP) granted local councils the legal mandate to make decisions on local issues, including authority for planning, resource mobilization, financial management, employment, business administration, and delivery of essential and local services. Local councils oversee, for example, district hospitals, health centers, dispensaries, and maternity clinics, and are responsible for management of the health budget. However, central government influence remains strong and decentralization is still far from complete.

Furthermore, support is needed for local councils and for new councilors who were elected in 2014, who are currently assuming responsibilities after a decade without such local leadership.

Ministry of Health (MOH) The MOH is responsible for issuing and enforcing health policies; regulating the health sector including the private health sector; developing and reviewing standards, norms, and management protocols for health service delivery, and communicating these standards to lower level institutions; planning and mobilizing health resources; advising other ministries, departments, and agencies on health-related issues;

providing technical support for supervision; coordinating research; and monitoring and evaluation. The MOH has responsibility for a number of WASH issues, including promotion of hygiene education and prevention of water and sanitation-related diseases.

Malawi operates a three-tiered service delivery system, encompassing primary, secondary, and tertiary levels of care. At the primary level, health surveillance assistants (HSAs), community– based distribution agents (CBDAs), and village health committees (VHCs) are responsible for basic health services provided via village clinics, mobile clinics or door-to-door. Primary health care centers also offer basic curative and maternal services and are staffed by nurses and clinicians. District hospitals, both private and public, are the secondary tier and the four tertiary-level central hospitals operate directly under the MOH.

According to the Health Sector Strategic Plan (HSSP) 2011 - 2016, the MOH also delivers approximately 60 percent of all health services, and the Christian Health Association of Malawi (CHAM) provides about 37 percent. CHAM facilities are quasi-public institutions, as the MOH governs policy at these facilities and is their major source of funds. The remainder (3 percent) of healthcare services is provided through the private sector, including private-for-profit entities (PfP), private-nonprofit entities (PnP), and small clinics offering care for company employees and their family members.

Ministry of Agriculture, Irrigation, and Water Development (MOAIWD): MOAIWD through the National Sanitation and Hygiene Coordination Unit (NSHCU) is responsible for implementing national sanitation and hygiene activities. However, the performance of this sector is hampered by the lack of a single, cohesive national sanitation policy, and efforts to invest adequately have been frustrated as a result. There is ambiguity over roles and responsibilities of the various stakeholders, including other ministries, and a lack of harmonization between existing policies and legal instruments dealing with these issues.12 The last National Water Policy was developed by the MOAIW in 2005, in part to ensure the sustainable delivery of water supply and sanitation services. As with sanitation and hygiene, water issues have also been hampered by ambiguity over roles and responsibilities of the various stakeholders, including those of other ministries. MOAIWD has recently tried to revise both of these overlapping policies but has yet to disseminate them.

Zonal Offices. Between the district and the central MOH is the zonal health structure, whose establishment was designed to provide technical, management, and administrative support, and to coordinate the activities of a cluster of up to seven districts in a zone. There are five Zonal Offices, namely North, Central West, Central East, South East, and South. These offices act as the technical extension offices of the central MOH.

District Level. Since the Decentralization Act of 1998, the Ministry of Local Government and Rural Development (MLGRD) has had overall responsibility for delivering health services at district, village and community levels through District Councils. The District Health Offices (DHOs) and District Health Management Teams (DHMTs) are formally part of the District Council administration. The MLGRD channels GoM funding for district health services to the District Councils and the Councils manage the funding. DHOs are co-signatories of the district health accounts. The MOH provides technical guidance and leadership, but does not provide direct administrative oversight to the districts.

During the current “partial devolution” phase, the GoM has had a dual public health structure—whereby district management structures exist in parallel with central MOH procedures, including annual planning and financial management. DHMTs report to both District Councils and the MOH; however, after years without fully functioning district councils, the DHMTs often have stronger relationships with the MOH. DHMTs are responsible for the development and implementation of District Implementation Plans (DIPs), which lay out planned health activities for the district. Each district has a District Environmental Officer and a District Water Officer.

Due to the nationwide health care worker shortage, most DHOs, who are responsible for managing the health budget, are recruited straight from college and have very limited experience in managing health programs or staff. Under the existing decentralization policy, the District Commissioner (DC) is the overall controller of the district’s public sector budget.

DHOs are mandated to work with the DC to plan for and implement the health sector budget.

With the decentralization policy and the election of District Councilors for the first time in a decade, district management is at a crossroads, and fiscal and administrative operations need more support and guidance than ever before.

CHAM is the largest, quasi-public organization providing health care, with 170 facilities and 10 pre-service training institutions. MOH contracts with CHAM to provide select FP/RH and MNCH services through Service Level Agreements (SLAs) in the predominantly rural areas where the MOH does not have sufficient coverage. As part of the devolution of health care services, the DHOs contract CHAM facilities in their districts to provide free reproductive and MNC health care. The contracted facilities receive payment from the GoM through the SLAs.

These SLAs vary widely in size, ranging from coverage of one health center to staffing large hospitals with several satellite health centers. The MOH has recently instituted ceilings on the number of services that can be paid to CHAM per month by reforming their Memorandum of Understanding with the association.

Private for Profit: The PfP sector is a largely hidden component in the health sector. While official MOH statistics show only one private health center, the GoM’s public-private partnership (PPP) strategy lists 465 such facilities.13 Based on a 2013 mapping exercise, USAID identified 763 private (PfP and PnP) facilities including CHAM and private pharmacies/drug stores, of which 40 percent are in Lilongwe and Blantyre, and 2,492 individual providers, of which 39 percent are PfPs. 14

PfP facilities provide services for fees and accept private health insurance coverage. PfP facilities provide a wide range of services, with 79 of these facilities accredited to provide anti-retroviral therapy. While many operate independently, the largest consortium of PfP facilities is the Blue Star program, with 34 private facilities for FP services.15

PfP health providers have minimal engagement with the MOH, even lacking a platform such as an association to engage the MOH at either the central or the district level (although such association was recommended in the HSSP). Officially, the Medical Council and Pharmacy, Medicines, and Poisons Board are tasked with registering PfP facilities. Although 98 percent of the private facilities claim to be registered, only 14 percent could show evidence of a formal registration certificate during a USAID-funded mapping exercise in 2013.16 In the mapping exercise, none of the PfP facilities had a SLA with the District Health Office. In urban areas especially, private providers play a more important role than presently reported, with the exception of treatment for under 5 illness.17 As has been experienced in other countries in Africa, demand for the private health services in Malawi is expected to grow.

Community-Level. In addition to the central MOH, the Zonal Offices, and the district-level health governance structures, the MOH has instituted structures at the district level whose purpose is to link the community to the different service delivery points (SDPs).18 These structures, which need assessments of their functionality, include:

● Health Center Management Committees in each district have responsibility for overseeing delivery of health services.

● Health Center Advisory Committees are composed of health workers from the health center and members of the community.

● Village Health and Water Committees promote primary health care activities through community participation, and work with HSAs to deliver preventative health services such as hygiene and sanitation.

C.2.2 Government of Malawi Health Sector Priorities, Strategies, and Policies.

As the overarching medium-term strategy to attain long-term development aspirations, the Malawi Growth and Development Strategy II (MGDS II) is a critical guiding document. The GoM’s HSSP 2011-2016 is the overall framework that guides the efforts of the MOH and all stakeholders in attaining the goals of the MDGS II and the Development and Cooperation Strategy for Malawi 2014-2018. The Essential Health Package (EHP) is a key HSSP component and consists of services, provided free of charge at the point of delivery, which address a multitude of medical conditions. The Activity must align with, and make major contributions to, the strategies, goals and outcomes of both the MGDS II and the HSSP follow

on. Although it is anticipated that the GoM’s follow-on to HSSP will retain similar principles and priorities, the Activity must be flexible enough to adapt to GoM changes. The HSSP has four key outcomes: 1) Increased coverage of high quality EHP services; 2) Strengthened performance of health systems to support delivery of EHP services; 3) Reduced risk factors to health; and 4) Improved equity and efficiency in the delivery of quality EHP services.

In addition to the MGDS II and the HSSP, the Activity must align with the full range of other GoM health and WASH sector strategies and policies, including: the National Health Policy, the National Strategic Plan for HIV and AIDS; National Reproductive Health Policy and Family Planning 2020 (FP2020) commitments; the Safe Motherhood Initiative; National Nutrition Policy and Strategic Plan; the Youth Policy, and the Open Defecation Free Policy 2011-2015. The GoM is also currently working on several critical elements of Universal Health Coverage and health financing, the Child Health Strategy and the Malaria Policy. In addition to the MOH district and zonal health entities, the Contractor must collaborate with other key GoM public institutions, including the Ministry of Finance, Economic Planning, and Development; Ministry of Agriculture, Irrigation, and Water Development; Ministry of Gender, Children, Disability, and Social Welfare; Ministry of Local Development and Rural Development; Ministry of Youth, Sports and Culture; and Ministry of Education, Science, and Technology (MOEST).

C.2.3 Development Partner (DP) Health Sector Programs A number of multilateral, bilateral, and foundation donors are involved in the health sector, including the Global Fund for AIDS, Tuberculosis and Malaria (GFATM); Norwegian Agency for Development Cooperation (NORAD); World Health Organization (WHO); World Food Program (WFP); United Nations Joint Programme on HIV/AIDS (UNAIDS); United Nations Population Fund (UNFPA); United Nations Children’s Fund (UNICEF); the Centers for Disease Control and Prevention (CDC); European Union (EU); Embassy of Norway; Deutsche Gesellschaft für Internationale Zusammena (GIZ); British Department for International Development (DFID); Icelandic International Development; African Development Bank; The Bill and Melinda Gates Foundation; and Clinton Health Access Initiative (CHAI). To maximize synergies and minimize duplication, this Activity must collaborate extensively with other DP programs, especially at the district level.

The MOH’s coordinating body for the sector is the Health Sector Working Group (HSWG), a cluster of institutions whose mandates share synergies and that use the HSWG to coordinate implementation of their activities. The HSWG resumed meeting in March 2014, after two years dormancy due to lack of MOH leadership. USAID participates in the HSWG, and the Contractor will be expected to participate in the appropriate technical area-specific working groups (see Annex 2).

C.2.4 Status of Priority Health Services

C.2.4.1 Maternal, Neonatal, and Child Health Status

Newborn Survival. Despite impressive gains in achieving MDG 4, neonatal, infant, and under five mortality rates remain unacceptably high at 2919, 5320, and 71 per 1,000 births, respectively. Neonatal mortality accounts for one-third of infant deaths and one-fifth of deaths among children under five years of age. The majority of newborns die within the first seven days of life, usually at home, and they primarily die from infections, prematurity/low birth weight, and asphyxia. After seven days, the major causes of infant and child deaths are pneumonia, malaria, diarrhea, HIV/AIDS, and malnutrition. This Activity is aligned with the global Every Newborn Action Plan and the Malawi Every Newborn Action Plan. O ther programs addressing newborn health and survival, include, but not limited to, the USAID Every Preemie-SCALE activity, the Survive & Thrive Global Development Alliance partnership, and the Gates Foundation’s Saving Newborn Lives activity.

Child Health: Malawi has low rates (38.5 percent) of immunization of children under two with all recommended vaccinations, including the newly introduced rotavirus and pneumococcal vaccines. Forty percent of child hospitalizations are for malaria. Under-nutrition, diarrhea, and pneumonia are critical factors contributing to poor health outcomes of children, and socioeconomic inequities in coverage of child health interventions persist.

Maternal Health. The maternal mortality ratio remains alarmingly high at 574 deaths per 100,000 live births despite having nearly 89 percent of pregnant women deliver in health facilities.22 The major causes of maternal mortality in Malawi are: postpartum hemorrhage, eclampsia, sepsis, and abortion-related complications. Twenty-six percent of girls age 15-19 have begun childbearing. Early childbearing is a major health concern because of the increased risks of death and disability to both mother and child during pregnancy and childbirth. Noting that 67% of the population is under the age of 25, it is not surprising that adolescent pregnancies comprise about 20 percent of maternal deaths in Malawi.23 The percentage of women ages 20-24 years that had at least one live birth before the age of 18 (31.3 percent of all pregnancies) severely affects the health and well-being of young women and their children.24

According to the Demographic Health Survey (DHS) 2010, 24 percent of women ages 15-19 years have already had a live birth; 6 percent are pregnant with their first child; and 1 percent has had a live birth before age 15.25 Early childbearing is more prevalent among rural (27%) than urban women (21%).26 Teenage mothers are more likely to have complications including preeclampsia, anemia, urinary tract infections, and fistula from prolonged or obstructed labor during delivery, resulting in higher morbidity and mortality. Children of adolescent mothers are more likely to die before the child’s fifth birthday. The detriment of early pregnancy is further compounded by rapid repeat pregnancies, which dramatically increase the likelihood of morbidity and mortality of young women and infants. According to the MDHS 2010, 15% of infants in Malawi are born less than two years after a previous birth. Thirty-eight percent of all pregnant women are anemic which contributes to complications, including postpartum hemorrhage.

Lack of access to quality services in both the public and private sectors during antenatal care (ANC), delivery, and postnatal care contribute to these statistics. Although Malawi has a high percentage (96 percent) of pregnant women seeking ANC from a health provider, only 44 percent attend ANC at least four times. Nearly half (48 percent) of Malawian women do not receive any postnatal care.

C.2.4.1 Family Planning/Reproductive Health (FP/RH). Malawi continues to make progress on FP/RH. According to the 2014 MDG Endline Survey, 58.6 percent of women married or in union reported current use of any contraception; 57.4 percent reported current use of modern contraception. However, the country struggles with a total fertility rate of 5 children per woman and an unmet need for family planning of 19.4 percent.27 Late adoption of FP leads to high fertility rates and an annual growth rate of 2.8 percent, one of the highest in the region.

Use of contraception is low among sexually active 15-to-19-year-olds, especially among married girls (25%). Fewer than 1 in 3 unmarried girls and 2 in 5 boys are using a modern method of contraception.28 In fact, youth represent a large proportion of the population that is not receiving adequate FP/RH services. Young people often face obstacles to accessing contraceptives and health services, and when accessed, they are often of poor quality therein increasing the risk of unintended pregnancies. Increasing access to information and services for adolescents, especially young adolescents (age 10-14), is a priority. Malawi’s key FP/RH challenges are persistent commodity stock outs, a poor mix of modern contraceptive methods, and poor access to long-acting reversible contraceptives (LARCs). To ensure that Malawi’s FP2020 commitments are met, a national plan to provide direction to Malawi’s FP programme, ensuring that all components of a successful program are addressed and budgeted for government and partner buy-in was developed. The Malawi Family Planning Costed Implementation Plan (FP-CIP), 2016–2020 has detailed plans to achieve Malawi’s vision and goals to improve the health and well-being of the country’s population.

C.2.4.2 Malaria. Malawi has made significant achievements in scaling up control and prevention interventions over the past 15 years. However, malaria continues to be a major public health problem and is endemic throughout the country. Transmission is year round in most areas, but peaks during the rainy season that typically runs November through April. The highest transmission areas are found along the hotter, wetter, and more humid low-lying areas of the lakeshore; highland areas typically have lower transmission rates.29,30 There are more than six million cases of malaria annually, which account for over 40 percent of all hospitalizations of children under 5 years of age, and 30 percent of all outpatient visits across all ages.31 Pregnant women and their fetuses, as well as children under 5 years of age, are at high risk of negative consequences of malaria and are therefore of special importance for prevention and control. Critical gaps remain in the use of long lasting insecticidal nets (LLINs); rational use of artemisinin-based combination therapy (ACTs) when correctly diagnosed; use of malaria rapid diagnostic tests (RDT) at facility and community level;

improved referral of severe malaria cases; and complete coverage of intermittent presumptive treatment of malaria in pregnancy (IPTp). The Activity aligns with the National Malaria Control Strategy and specifically the annual President’s Malaria Initiative (PMI) Malaria Operational Plan (MOP) and malaria interventions are implemented in accordance with the WHO’s latest practices and guidelines.

C.2.4.3 Nutrition. Under-nutrition remains a substantial and persistent public health and development challenge. The prevalence of stunting among children under five years old is at 42 percent, and 17 percent are underweight. In recent years, select nutrition interventions have achieved high coverage, but gaps remain. For example, 71.9 percent of children under the age of five months are exclusively breastfed. However, the Minimum Acceptable Diet for children aged 6-23 months is consumed by only 15 percent of this age group.32 Malnutrition of children under 5 remains a significant issue in all districts, as does anemia in women of reproductive age and adolescents, both pregnant and not pregnant. Because of limited ANC visits, iron supplementation may not be taken, making women more at risk for death if there is any pregnancy related bleeding, and they are more likely to have a smaller or preterm babies.

C.2.4.4 Water, Sanitation, and Hygiene. The current burden of disease and their associated risk factors clearly indicate the need for WASH interventions, and particularly those associated with household environmental health and indoor air pollution. Seventeen percent of years of life lost (YLL) are due to lower respiratory infections and diarrheal disease. Diarrhea continues to be a major cause of morbidity especially for children. According to one study, 24 percent of children under 5 had diarrhea in the last two weeks before the survey.33 Only 41 percent of the household members are using improved sanitation facilities that are not shared.

In rural areas, the percentage is 39 percent, compared to 49 percent in urban areas. Fifteen percent of households from the poorest wealth index quintile have no sanitary facility, but use the bush or fields to dispose of excreta. A specific place for hand washing was observed in only 11 percent of households, and in only four percent was there water and soap available for appropriate hand washing. Current WASH-related activities include: water supply construction; community BCC and engagement; governance through technical assistance and monitoring; and private sector engagement (e.g., sanitation/WASH marketing). Water supply and sanitation service delivery largely exists outside of the health system with different actors than those involved in health service delivery and require engagement with the Ministry of Agriculture, Irrigation, and Water Development, local government including zonal water offices and village water committees, and private sector actors relevant to sustainable WASH services.

C.2.4.5 Health System Status Malawi has the third lowest GDP per capita in the world35 and the GoM expends only $7.60 per capita per annum on health.36 Substantial donor resources bring Total Health Expenditures to $39 per capita per annum, compared to an average of $147 for the Southern African region. As a result of such extreme resource constraints, the country lacks the basic health system requirements to meet the service delivery needs of its population.

Malawi is tied with Niger for 190th among 193 countries with data on physicians per capita and 174 of 189 on nurses per capita.i37 Fifty-two percent of established positions in the health sector are vacant, with substantial gaps at both MOH headquarters and service delivery points.

The majority of health facilities are inadequate to accommodate the increase in patient volume resulting from the country’s rapid population growth. Extreme gaps in HRH and infrastructure are exacerbated by low district capacity to: 1) manage district financial and human resources;

2) report and analyze information; and 3) plan and coordinate the multitude of partners in the health sector at the district level. A reliable Human Resource Information System is an important tool to facilitate strategic management of HRH. As such, under SSDI-Systems, USAID supported the MoH to pilot and then scale up a web-based, integrated Human Resource Information System (iHRIS). iHRIS is currently in use throughout the country, but gaps persist in the quality and completeness of data for which District Human Resource Officers are responsible. Also under SSDI-Systems, USAID supported the MoH to develop and pilot an Integrated Supportive Supervision (ISS) Tool using mobile technology that was rolled out to all 15 SSDI districts by 2014. This tool combines key indicators from each program area into a single tool on a mobile phone, with the aim of streamlining the multiple, parallel supervisions by vertical programs. In addition, the tool: 1) includes a user-friendly, color-coded dashboard to provide a real-time snapshot of facility performance on the supervisor’s phone; 2) sends alerts to stakeholders at district, zonal, and central level regarding facility performance; and 3) connects to a national dashboard (also accessible at district level) that allows for analysis of service delivery performance over time.

C.2.5 Relationship to GoM and CDCS Priorities

CDCS: USAID/Malawi’s CDCS addresses development challenges enunciated by the GoM through an integrated approach that concentrates resources programmatically and geographically where and when feasible38 (See Annex 3). Through what it is calling a “3-C Approach,” USAID integrates development activities by:

● Co-locating interventions to the extent that it is sensible;

● Coordinating better within USAID and with other Development Partners (DPs); and

● Collaborating to foster linkages among implementing partners and the DPs to improve results, and sustainability.

USAID hypothesizes: if assistance is integrated then development results will be enhanced, more sustainable, and lead to achievement of our CDCS goal: Malawians’ quality of life improved. This will be done through improvements in social development, sustainable livelihoods, and strengthening of citizens’ rights and responsibilities. This hypothesis concentrates resources by delivering integrated, inclusive development results to targeted communities. Health is an essential CDCS component implemented through the 3-C Approach.

Integrated Health Project: In 2014, to support the CDCS, the Health Office developed the five-year IHP that uses integrated approaches to health challenges to reduce maternal, newborn and child morbidity and mortality as well as the HIV prevalence. The IHP recognizes that weak policies, lack of capacity at all levels, inadequate use of innovation and technology, and slow adoption of social behavior change are all structural problems that need to be addressed.

IHP hypothesizes that if health services are improved and effectively used, then the health status of Malawians in the targeted districts will also improve. All IHP awards, including the Activity, specifically contribute to attaining the CDCS goal of Malawians’ quality of life improved through DO 1: Social development improved. DO 1 incorporates expanding the availability and quality of essential social services, including health services, and posits that a healthy, educated population is essential to improving citizens’ social development and their livelihoods.

IHP also directly supports the GoM’s HSSP 2011-2016 and the MGDS II goals to improve the quality of life of all Malawians by reducing the risk of ill health and the occurrence of premature deaths, thereby contributing to social and economic development. IHP’s purpose, indicators and targets are shown in Table 1. With the exception of the two for HIV/AIDS, the baseline targets are derived from the 2014 MDG Endline Survey. Reductions in the number of new HIV infections and reductions in HIV-related deaths are also part of USAID/Malawi’s overarching targets; however, this Activity will not include funding from the President’s Emergency Program for AIDS Relief (PEPFAR). Nevertheless, the Contractor must coordinate and collaborate with separate PEPFAR, GoM, and other DP activities that cover HIV programming in targeted districts. (See C.9 for Integration Opportunities).

C.3 SCOPE

The purpose of this Activity is to provide technical assistance and operational support in the GoM’s efforts to reduce maternal, newborn, and child mortality through improved access to MNCH, malaria, WASH, and FP/RH services; improved quality of these priority health services; strengthened district health systems; and increased community demand for these priority services.39 The Contractor must provide technical assistance and operational support to the GoM in these efforts. The focus is primarily at the district, facility, and community levels but includes targeted assistance at central and zonal levels in key areas that impact service delivery.

IHP Purpose Indicators and Targets are listed in Table 1. The Activity will make significant contributions to achieving the maternal, infant, neonatal, and child mortality targets, the modern contraceptive prevalence rate target, and the prevalence of stunted children target.

Table 1: IHP Purpose Indicators and Targets

Indicators

DHS

DHS

2010 Baseline Baseline

IHP

Targets

Data Sources

201440 201541

Maternal Mortality Ratio/100,000 live births 984 675 574 TBD 450 DHS, MDG

Infant Mortality/1,000 live births 76 66 53 TBD 40 DHS, MDG

Neonatal mortality rate/1,000 live births 27 31 29 TBD 27 DHS, MDG

Modern Contraceptive Prevalence Rate 28% 42% 57.4% TBD 60%* DHS, MDG, FP2020, CIP

Number of new HIV infections (adults and children)

N/A

60,866

43,431

TBD

22,491

2010,2014 Malawi Investment Case2015,2020 IHP Targets:

NSP 2014

Number of HIV-related deaths (adults & children) N/A N/A 48,000 TBD 20,113 2014: Country Progress Report

(UNGASS)

Prevalence of stunted children under 5 53% 47.1% 42.4% TBD 38% DHS, MDG

* Baseline figures for MCPR have historically represented women in union; however the FP2020 commitments have revised the national objective to represent all women of reproductive age, with a focus on ages 15-24. This target is in line with the 2015 Malawi Costed Implementation Plan.

C.4 OBJECTIVES

The overarching purpose of the Activity is to reduce maternal, newborn, and child morbidity and mortality. These aims contribute to achieving the IHP purpose: Health status of Malawians in targeted districts improved, and the CDCS DO 1: Social Development Improved. Like the IHP, the Activity hypothesizes that if health services are improved and effectively used, then the health status of Malawians in targeted districts will also improve.

Diagram 1 summarizes the Activity purpose and its linkages to the CDCS DO 1 and the IHP purpose.

The Activity will also build on previous health sector investments, leverage opportunities for increased integration, and lay the foundation for sustainability. By providing comprehensive health services, strengthening health systems, building the capacities of communities, and addressing the marginalization of women and youth, the Activity will also contribute significantly to the CDCS cross-cutting SIR 1: Capacity of institutions improved, and SIR 4:

Positive behaviors adopted.

The Activity will contribute to the following overarching indicators:

● Reduction in the maternal mortality rate (MMR)

● Reduction in under-five mortality rate (U5MR)

● Reduction in the infant mortality rate (IMR)

● Reduction in the neonatal mortality rate (NMR)

● Increase in the modern contraceptive prevalence rate (MCPR)

The actual targets for maternal mortality, under-five mortality, infant mortality, neonatal mortality, and MCPR as well as interim targets needed to achieve these over-arching targets will be determined based on Malawi’s 2015 DHS, preliminary results of which are expected in April 2016. The Contractor may propose additional indicators and targets for each of the Activity’s accompanying IRs and SIRs. The Contractor must also report on all applicable standard USAID F indicators, indicators required in the IHP, and any additional custom indicators.

Diagram 1: ONSE Athanzi Results Framework and Linkages to CDCS

IR 1: Access to priority health

IR 2: Quality of priority health

IR 3: Performance of health

IR 4: Demand for quality priority health services increased

Cross-cutting themes:

CDCS Integration across activity areas and technical teams

Gender and Youth Private Sector Engagement

IHP Goal

IHP Purpose

C.5 STRATEGIC PRINCIPLES AND CROSS CUTTING THEMES

The Contractor must adhere to the following strategic principles and incorporate the following crosscutting themes into the Activity.

C.5.1 Strategic Principles

“Smart” Capacity-Building and Problem Solving Approaches. “Smart” approaches mean designing programs that extend beyond “business as usual.” “Smart” capacity building requires innovative and/or evidence-based methods to strengthen organizational and individual capacity without relying entirely on traditional training approaches. An over-reliance on group training events has questionable effectiveness in building and sustaining capacity of staff to manage and deliver health services and consequently leaves health units shuttered while trainees are offsite. A creative, “smart” approach to capacity development includes a multi-pronged approach that is thoughtful, targeted and sustainable and does not come at the expense of other services. Approaches must extend beyond one-time off-site trainings while also taking into account provider motivation and retention.

“Smart” problem solving involves supporting districts and facilities to analyze epidemiological, sociocultural, socioeconomic, and sociopolitical data, and then tailoring interventions to meet the specific needs of the district and community partners. Districts, facilities, and communities are key to defining local problems and identifying local solutions.

In addition, “smart” problem solving involves supporting districts and facilities to identify priority gaps in…