RFP-SOL-612-16-000006_Health_SBCC.pdf

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SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS:

B.1. SERVICES

The purpose of contract is for the Contractor to implement the Health-Social and Behavior Change Communication (Health-SBCC) 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, he 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 of 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].

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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 shall 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 Cost

001 Health-seeking practices improved

002 Government of Malawi (GoM) capacity to lead national SBCC programming improved

003 Capacity of key institutional partners to design, implement, and evaluate high-quality SBCC improved

004 Improved use of data for decision making in SBCC

Total Direct Costs Per Year

Total Indirect Costs Per Year

Fixed Fee Total Cost Plus Fixed Fee

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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. Boxes marked “x” denote years in which that activity deliverable or Performance Objective/Output is not required.]

No. Performance Objective

Deliverable / Output Reference Section

Amount Year 1 Year 2 Year 3 Year

Year

Activity Deliverable 1 Activity Monitoring, Evaluation and Learning F.5.1 x x x x

2 Annual Work Plans F.5.2 3 Five Year Implementation

Plan F.5.3 x x x x

4 Quarterly Activity Reports F.5.4 5 Quarterly Financial Reports F.5.5 6 Consultant Reports and Short

Term Technical Assistance (STTA) Reports

F.5.6

7 Monthly Update Reports F.5.7 8 Annual Activity Reports F.5.4 9 Final Report F.5.8 x x x x Performance Objective/Output

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ESULT

AREA

DELIVERABLE

Reference section Yr 1 Yr 2 Yr 3 Yr 4 Yr 5

CLIN001

IR. 1. Health-seeking practices improved

1-1. Formative research report (household survey) documenting Malawian men and women’s knowledge, attitudes and practices of the following:

determinants of foodborne illnesses; food safety (especially pertaining to aflatoxins); the human cost of misused and stolen government resources and understanding of available channels to demand accountability.

C.6.IR1 x x x x

1-2. Design and review annually a national health communication campaign, in collaboration with the GOM focusing on the priority health areas of: FP, MNCH, Nutrition, WASH, malaria, food safety and the human cost of misused and stolen government resources.

C.6.IR1

1-3. Annual implementation plan of the national health communication campaign developed with GOM and approved by the COR.

1-4. Successful implementation of activities approved in the annual national health communication campaign implementation plan

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1-5. Annual design, publication and distribution plan of standardized tools to support community mobilization interventions developed with GOM and approved by the COR.

1-6. Successful implementation of activities approved in the annual design, publication and distribution plan for SBCC health campaign implementation plan.

1-7. Endline household survey developed with resulting report assessing Malawian men and women’s knowledge, attitudes and practices of the following: determinants of foodborne illnesses;

food safety (especially pertaining to aflatoxins);

the human cost of misused and stolen government resources and understanding of available channels to demand accountability.

C.6.IR1 x x x x

CLIN002

IR 2 GoM capacity to lead national

SBCC

programming improved

2-1. Stakeholder Mapping Report detailing government and non-government institutions active in SBCC and health communications at the national, zonal and district levels. The mapping must identify overlaps and gaps in SBCC interventions

C.6.IR2 x x x x

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2-2. Capacity Strengthening Assessment of GOM’s capabilities in design, coordination, implementation or evaluation of health SBCC programming. The assessment design must be scientifically rigorous, developed in collaboration with the GOM and approved by the COR.

C.6.IR2 x x x x

2-3. Annual Capacity Strengthening Plan to support GOM to lead the design, monitoring, coordination and implementation of the national health SBCC programming messages and standards. The Capacity Strengthening Plan must be developed in collaboration with the GOM and approved by the

COR.

C.6.IR2

2-4. Successful achievement of capacity building activities for GOM as stipulated in the Annual Capacity Strengthening Plan.

C.6.IR2

2-5. Collaborate with GOM to develop two or more innovative methods/technologies in the design, implementation and evaluation of SBCC interventions

C.6.IR2 x x x

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CLIN 003

IR 3 Capacity of key institutional partners to design, implement, and evaluate high-quality SBCC improved

3-1. Capacity Strengthening Assessment of key non-government institutions active in the design, implementation or evaluation of health SBCC programming. The assessment design must be scientifically rigorous, developed in collaboration with the key stakeholders and approved by the COR

C.6.IR3 x x x x

3-2. Annual Capacity Strengthening Plan to support the strengthening of technical and operational capacity of key non-government institutions active in health SBCC. The Capacity Strengthening Plan must be developed in collaboration with the key stakeholders and approved by the COR.

C.6.IR3

3-3. Successful achievement of activities of key non-government institutions active in health SBCC as stipulated in the Annual Capacity Strengthening Plan.

C.6.IR3

3-4. Collaborate with key non-government institutions active in health SBCC to develop two or more innovative methods/technologies in the design, implementation and evaluation of SBCC interventions

C.6.IR3 x x x

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CLIN 004

IR 4

Improved use of data for decision making in

SBCC

4-1. National monitoring and evaluation system for SBCC established and functional. The system must be integrated to the national health information system (e.g. DHIS 2), routinely collect and report SBCC data nationally to inform decision-making and serve as a system for routine information exchange. The system will be reviewed annually for functionality by the GOM and validated by COR.

C.6.IR4

4-2. Annual SBCC Data Use Plan to support improved application of evidence from research and monitoring and evaluation to inform management of nationwide SBCC programming and increased use of data to improve program planning, implementation and impact.

4-3. Successful achievement of activities in the annual SBCC data use plan.

4-4. Successful coordination of an annual meeting for exchange and dissemination of technical information and programmatic learning for SBCC stakeholders at all levels.

4-5 Publication of a

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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: $500,000.00

Contract Year 3: $800,000.00 Contract Year 4: $500,000.00 Contract Year 5: $400,000.00

[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]

minimum of two articles in a peer-reviewed journal documenting research 4-5., Project documentation and dissemination plan highlighting program experiences and policy briefs on SBCC in Malawi.

The articles must include work of the contractor in a peer-reviewed journal.

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SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK:

C.1 INTRODUCTION

Health-Social and Behavior Change Communication (Health-SBCC or Activity) will support the Government of Malawi’s efforts to increase demand for quality sustainable priority health services and products, by improving the ability, opportunity, and motivation of individuals to utilize these resources, and the capacity of the GoM to lead and key institutional partners to support national SBCC programming. The Activity will build national health SBCC capacity and conduct key health communication interventions to increase demand for the priority services of maternal, neonatal and children health (MNCH), HIV, family planning and reproductive health (FP/RH), nutrition, malaria and water and sanitation, and hygiene (WASH). The Activity will also contribute to the improvement of the health status of Malawians and to the achievement of USAID/Malawi’s Country Development Cooperation Strategy for 2013-2018 (CDCS) Development Objective 1 (DO1): Social development improved.

Over the last two decades, Malawi has achieved dramatic gains in most health indicators by focusing on the improved delivery of essential health services.1 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 2013,2 and increased the contraceptive prevalence rate for married women from 7.4 percent in 1992 to 42 percent in 20103, 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 2010.4 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 5,5 Malawi's population could more than triple to over 50 million by 2050. 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.6 Even with the gains in child health, almost one-half (42.4 percent) of children are stunted.7 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.8 Nearly half of the established positions in the health sector are vacant, and a perpetual shortage of qualified health workers persists.9 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.

1 As they are the most recent, MDG Endline Survey 2014 results have been used whenever possible. However, Malawi Demographic Health Survey 2015 results will be used as the baseline when they become available in 2016.

2 MDG Endline Survey 2014 3 Malawi Demographic Health Survey 2010 (DHS 2010) 4 UNAIDS Spectrum Modeling 2014 5 MDG Endline Survey 2014 6 Ibid 7 Ibid 8 Malaria Indicator Survey 2014 9 iHRIS, 2014

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SBCC or health communication is defined as the coordinated use of a range of communication approaches – including mass, print, and social media, community and interpersonal communication (IPC) messaging - to influence individual and collective behaviors and social norms in support of improved health outcomes. High-quality SBCC is an essential element of health programming as it shapes not only demand, but also client-provider communication, couples’ communication, and engagement of community leaders and other influencers. The Activity will provide unique opportunities for strengthening national capacity, building leadership, and improving coordination for sustained health outcomes, all of which will contribute towards achieving the GoM and USAID/Malawi CDCS’ goals of building a healthier Malawi. Health-SBCC will support the GoM and the Ministry of Health (MOH) to better coordinate and lead national health communication across a variety of key stakeholders, including standardized health communication materials development and training through the zonal and district levels

The purpose of the Activity is to increase demand for quality priority health services. To accomplish this, the Contractor must execute evidence-based or innovative SBCC interventions related to FP/RH, MNCH, HIV, nutrition, malaria, and WASH that contribute to the achievement of the four interrelated and interdependent intermediate results (IRs):

IR.1 Health-seeking practices improved IR.2 GoM capacity to lead national SBCC programming improved IR.3 Capacity of key institutional partners to design, implement, and evaluate high-quality

SBCC improved IR.4 Use of data for SBCC decision making improved

C. 2 BACKGROUND

C.2.1 Development Problem Malawi’s improvements in most health indicators over the past two decades have been achieved by focusing on the improved delivery of essential health services. It is one of a 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 2013,10 and increased the contraceptive prevalence rate for married women from 7.4 percent in 1992 to 42 percent in 2010.11 In addition, the human immunodeficiency virus (HIV) prevalence among 15-49 year old men and women declined from 12 percent in 2004 to 10 percent in 2010.12

These broad gains, however, mask important country realities and structural dynamics in the health system that must be addressed if the advances of the past two decades are to continue. The country continues to face challenges posed by population dynamics such as high fertility and mortality rates; a youth bulge with 52 percent of the population less than 18 years of age;

10 MDG Endline Survey 2014 11 Malawi Demographic Health Survey 2010 (DHS 2010) 12 UNAIDS Spectrum Modeling 2014

15 | P a g e unemployment; and environmental degradation. At the current annual rate of growth of 2.8 percent, it is estimated that Malawi’s population of approximately 16.4 million people will nearly triple by 2050.13 Such a rapidly increasing population will undermine the GoM’s ability to provide quality social services in various sectors, including health, education, and housing. It will also accelerate both depletion of natural resources and degradation of land and the environment.

Married women have a high-unmet need for family planning (FP) services (19.4 percent), with particularly acute needs among young people.14 Close to one million people in the country live with HIV, with approximately 34,000 new infections each year.15 Even with the gains in child health, almost one-half (42.4 percent) of Malawian children are stunted.16 Malawi is a high-burden malaria country with an estimated incidence rate of 332/1,000, and the MOH estimates there approximately 6 million episodes of malaria per year. Diarrhea continues to be a major cause of morbidity among children under five years old. When surveyed in 2014, almost one-fourth (24.1 percent) had diarrhea within the preceding two weeks.17 Only 40.6 percent of the population has access to improved, not shared, sanitation facilities.18 Such tremendous health challenges, combined with constrained economic resources and marginalized women and youth, place an onerous burden on the health system. This burden is exacerbated by a lack of accountability for the resources the health sector does have, an issue that is forefront due to recent reports that underscore longstanding issues of drug pilferage and misuse of government funds.

C.2.2 Health and Sociocultural SBCC Challenges Sociocultural Norms and Issues: A number of very deep-rooted beliefs and practices at the heart of Malawian culture and society, especially those involving gender and youth, powerfully restrict the adoption of health seeking behaviors, including the use of priority services.

Improving the availability of integrated, quality services will have limited impact unless Malawians demand and use these services.

Malawian society is traditional and often fosters patterns of health-seeking behaviors that delay or limit beneficial contact with health professionals. The generally low status of women, especially young women, greatly impacts their health status and use of services. More women than men are infected with HIV at every age group; gender-based violence (GBV) remains a serious health challenge and is considered a male prerogative. Malawi ranks among the most youthful countries with two-thirds, or 67 percent, of its population under the age of 25, and is faced with an extremely high teen pregnancy rate of 26 percent.19 However, parents and

13 RAPID: Population and development in Malawi. Lilongwe, Malawi: Population Unit, Ministry of Development Planning and Cooperation. 2012. Page 7 14 MDG Endline Survey 2014 15 HIV Investment Case estimate 2014 16 MDG Endline Survey 2014 17 MDG Endline Survey 2014 18 Ibid

19 DHS 2010

16 | P a g e community leaders often disapprove of youth accessing reproductive health (RH) services, and youth friendly health services (YFHS) at facilities are limited and poorly resourced.20

For women and girls, the lack of empowerment and harmful cultural practices (e.g., early marriage and early first pregnancy); limited education; harmful taboo and stigma and acceptance of GBV adversely affect their health status and that of their families. These factors place women at higher risk of communicable diseases and unintended pregnancies. The ability of caregivers, primarily women, to make prompt decisions about care seeking for their children is often hampered by the woman’s educational level and need for spousal or village elders’ consent. For men, public health initiatives have often sidelined their needs for participation and empowerment, albeit in different ways than for women. Gender norms often mean that men act as gatekeepers around the use of health services, although they often lack knowledge about or access to health services, be it FP/RH, child health, or infectious diseases including HIV.

Traditional male gender norms encourage men to equate a range of behaviors, such as violence, substance abuse, and multiple partners, with being manly.

Cultural beliefs around “zaboma” – meaning abuse of government resources is acceptable and does not hurt anyone – also hinder efforts to ensure that government health resources are used for their intended purpose.

Maternal, Neonatal and Child Health: Maternal and newborn deaths are largely preventable and are, in part, indicative of, low demand for and use of health services. Maternal mortality remains alarmingly high at 574 deaths per 100,000 live births, despite having nearly 89 percent of pregnant women deliver in health facilities.21 Adolescent pregnancies comprise about 20 percent of maternal deaths.22 The major causes of maternal mortality, which can in part be prevented by relatively simple, evidence-based interventions, are: postpartum hemorrhage, eclampsia, sepsis and abortion-related complications. Lack of information about the life-saving interventions, and sociocultural barriers to use of antenatal care (ANC), delivery, and postnatal care and other services, are largely responsible for the negative statistics.

While there has been a slight decrease from 31 to 29 per 1000 live births (2010/2014), neonatal mortality accounts for one third of infant deaths and one-fifth of deaths among children under-five years.23 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. Despite dramatic gains in achieving MDG 4, the under-five mortality rate remains unacceptably high at 85 per 1000 births.24 As with maternal mortality, much of neonatal and child mortality is caused by lack of information about often simple life-saving interventions and/or sociocultural barriers that inhibit the use of these interventions. Increased knowledge and

Evaluation of Youth Friendly health services in Malawi; GOM & USAID, 2014

21 MDG Endline Survey 2014

22 DHS 2010

23 MDG Endline Survey 2014 24 Ibid

17 | P a g e use of childhood immunizations, long-lasting insecticidal nets (LLINs), kangaroo care, and exclusive breastfeeding for six months, for example, would contribute significantly to a decrease in neonatal and under five mortality and morbidity.

Family Planning/Reproductive Health: Malawi continues to make progress on FP/RH, as demonstrated by a high contraceptive prevalence for married women of 58.6 percent. However, the country struggles with a total fertility rate of 5 children per woman, and an unmet FP need of

19.4 percent for married women 15-49 years.25 Late adoption of FP leads to high fertility rates and women’s low levels of educational attainment and their early marriages result in the high adolescent fertility rate of 143 per 1000 women aged 15-19. Twenty-six percent of women between the ages of 15-19 have begun childbearing.26 Of the currently sexually active unmarried 15-19 year olds, only 31 percent have ever used modern contraceptives.27 Furthermore, there is an unmet need for family planning methods reported at 24.9 percent among young married women aged 15-19.28

Research is needed to determine the reasons behind these issues and how behavior change strategies should be targeted. Research and messaging should focus specifically on those barriers, e.g., persistent myths, misconceptions, stigma and provider bias. Youth represent a large proportion of the population that is not receiving adequate services, and increasing access to services for adolescents, especially young adolescents, is a priority. FP knowledge is 98 percent, yet only 5 percent of women use contraception before their first child. In rural Malawi 46 percent of currently married 15-49 year old women and 42 percent of currently married 15-49 year old men report wanting no more children. Furthermore, 28 per cent of married rural women want to space or limit the number of children but are not using a FP method. 29This data provides an opportunity for Health –SBCC to promote the advantages of having fewer children through targeted and focused messaging.

HIV/AIDS: HIV/AIDS remains a serious challenge to achieving the health and development goals of the Government of Malawi (GOM) as well as those of the U.S. Mission to Malawi. While HIV prevalence among 15-49 year old men and women has declined from 12.0% in 2004 to 10.6% in 2010, Malawi still faces an estimated 34,000 new infections and 48,000 HIV-related deaths annually30. There are nearly 1,000,000 people infected and living with HIV, of whom 170,000 are children under the age of 15 years (SPECTRUM modelling)31. Social development will continue to be slowed by HIV until incident infections can be reduced substantially, and populations infected and affected by HIV are reached through cost-effective and sustainable HIV prevention, care, treatment, and mitigation services.

Targeting populations most affected and vulnerable to HIV with comprehensive HIV services is critical to having rapid and sustained impact on the epidemic. There is a unique geographic and

25 Ibid

26 DHS 2010

27 Ibid 28 Ibid 29 Ibid.

30 Demographic Health Survey (2010), Modes of Transmission Study (2013) 31 Ibid

18 | P a g e demographic distribution of HIV prevalence in Malawi, with significant variations between urban and rural communities, women and men, children, youth and older persons. Prevalence in urban areas is twice that of rural areas, with the highest prevalence in the larger towns and cities of the South (17.6% prevalence) and Central (10.7% prevalence) districts. Women in urban areas have an even higher prevalence of 22.7% compared to their rural counterparts (10.5%)32. Malawi’s high population growth rate translates to a sizeable at risk youth population.

Young people (15-24) constitute 16.1% of the population, and account for approximately half of all new HIV infections33. Other subpopulations, including truck drivers, male vendors, fishermen, male and female school teachers, male and female police officers, female border traders, and female sex workers, were highlighted within the Modes of Transmission Study (MOT) and 2006 Behavioral Surveillance Survey (BSS) as populations at increased risk, based on higher than average prevalence34. High HIV prevalence in areas is correlated with high economic activity such as road networks, rural estates, borders, and urban manufacturing and marketing zones35.

Underpinning prevalence and vulnerability are critical social and traditional barriers to adoption of specific behaviors and services across the prevention and care continuum. These include:

The low status of women in society and their consequent low self-efficacy to negotiate various issues with their partners (condom use, getting testing, disclosure of positive status, etc.);

The low status of adolescent girls that leads to a casual societal attitude about early sexual debut, inter-generational and transactional sex, forced sex, early marriages, Gender-Based Violence (GBV), and lack of prioritization for girls education;

Poverty drives vulnerability of children and families and contributes to risk behavior, low access to health services, and educational opportunities;

The lack of comprehensive HIV/AIDS knowledge that contributes to poor assessment of risk behaviors, and social acceptance of multiple, concurrent sexual partnerships;

Stigma and discrimination which inhibits timely health seeking behavior, disclosure, and long-term adherence; and

High levels of violence against children and women in homes, schools, and communities.

Despite this serious epidemic, some notable improvements have been made in the national HIV response. Rapid scale up of ART between 2004 and 2014 has dramatically reduced mortality, morbidity and transmission of HIV. Most recently, the Malawi Government has set out an ambitious plan to reach the 90/90/90 targets within the National Strategic Plan for HIV (2015- 2020). The target refers to three key steps to achieve better health and care for people living with HIV and to minimize new infections.

90% of Malawians living with HIV will know their status.

32 UNAIDS (2011), Malawi HIV and AIDS monitoring and evaluation report: 2008-2009.

http://www.unaids.org/es/dataanalysis/monitoringcountryprogress/2010progressreportsubmittedbycountries/file 33 Ibid 34National AIDS Commission, Biological and Behavioural Surveillance Survey 2006 & Comparative Analysis of 2004 BSS and 2006 BSS 35 National Strategic Plan for HIV/AIDS (2015-2020)

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90% of all those who are diagnosed with HIV infection will receive sustained antiretroviral treatment (ART).

90% of all people receiving ART will have viral suppression.

Achievement of 90/90/90 objectives will be predicated upon synergistic implementation of targeted community prevention, care and support, and impact mitigation activities linked to provision of quality facility based treatment and care services. Successful identification of unknown positives within communities and linkage to care is a critical priority. Bottlenecks within the care continuum also need to be addressed through community mobilization, normative and operational change for effective linkages, community case management, strengthened PLHIV support, and addressing the holistic needs of vulnerable children and families. Integrated responses leveraging prevention and OVC platforms can support early identification while also improving treatment retention and adherence. One Community, working in close collaboration with funded facility based partners, is leading on community efforts in 8 priority PEPFAR districts in the South. Nevertheless, concerns around broader treatment literacy which impact on uptake and retention of HIV services across all districts, need national leadership for coordination, mass media support and broader dissemination of effective communication strategies/tools developed.

Malaria: Malaria is endemic throughout the country. Despite gains, the MOH estimates that there are more than six million episodes of malaria per year, with the disease accounting for over 40 percent of all outpatient visits. Pregnant women and their fetuses, as well as children under 5 years of age, are at high risk of the negative consequences of malaria, and are therefore of special importance for prevention and control. Gaps remain in prompt care seeking for fever in children;

use of LLINs; rational use of artemisinin-based combination therapy (ACTs); use of and adherence to rapid diagnostic tests (RDTs); facility and community referrals of severe malaria cases; and complete coverage of intermittent presumptive treatment in pregnancy (IPTp).

According to MIS 2014 findings, IPTp coverage of two doses has stagnated around 63 percent, while LLIN ownership and use have not reached universal coverage. Barriers to the uptake of key preventive measures include beliefs among the populace that every fever is malaria; that malaria is a normal occurrence and is not worrisome; safety concerns or misinformation regarding sleeping under LLINs; indoor residual spraying; and the use of IPTp.

Nutrition: Under-nutrition remains a substantial, persistent public health and development challenge, and effective SBCC interventions are needed to address it. In addition to the high prevalence of stunting among children under five years old 16.7 percent are underweight.36 High coverage of some nutrition interventions has been achieved in recent years, but significant gaps remain. For example, 71.9 percent of children under the age of five have been exclusively breast fed until six months old, but only 15 percent of children aged 6-23 months receive the Minimum Acceptable Diet. While rural households have increased their total calorie consumption across all income quintiles in recent years, the bulk of the additional calories come from staple foods, and predominantly from maize.37 Thus, even though the calorie shortfall has decreased for most rural households, shortfalls of both iron and Vitamin A, key micronutrients, have actually

36 MDG Endline Survey 2014 37 Third Integrated Household Survey, 2010-2011.

20 | P a g e increased, and are now at 49 and 70 percent respectively.38 The nutrition needs, and particularly the micro-nutrient needs, of rural households are thus largely unmet. Nutrition behavior change efforts are needed to address key micro-nutrient shortfalls, particularly for pregnant and lactating women and children under two.

Reducing consumption of aflatoxin-contaminated foods is also critical to reducing child stunting and improving nutrition and health outcomes in Malawi. Aflatoxin, a Class 1 human carcinogen, is a byproduct of naturally occurring fungi that infect many crops. In Malawi, dangerously high levels of aflatoxin contamination are especially prevalent in maize and groundnut, two major staples in the Malawian diet. Aflatoxin is also passed to humans through the consumption of contaminated meat and milk, including human breast milk. Consumption of high levels of aflatoxin leads to liver cancer, immunosuppression, and in extreme cases, acute poisoning.

Evidence from sub-Saharan Africa increasingly links aflatoxin consumption to stunting of children under five, and long-term cognitive impairment. Reducing consumption of aflatoxin in the diets of pregnant and lactating women and children under five (with a special focus on children under two) is therefore critical to achieving meaningful reductions in child stunting.

Aflatoxin has long been viewed as an agriculture and trade issue, and has only recently been increasingly linked to negative nutrition and health outcomes. A comprehensive approach to addressing aflatoxin is needed, as it is necessary to affect behavior change in the production, drying, storage, processing, and preparation of maize and groundnut. Mothers and care givers must be targeted with behavior change in order to reduce unsafe levels of aflatoxin consumption.

Water, Sanitation and Hygiene (WASH): WASH issues are still critical `in Malawi. Despite having over 85 percent of household members using improved sources of drinking water, only

4.2 percent of households have a specific place for hand washing where water and soap (or other cleansing agent) is present.39 Diarrhea continues to be a major cause of morbidity in Malawi, as 24 percent of children under 5 years old had diarrhea in the two weeks preceding a 2014 survey.40 WASH also affects all aspects of food and livelihood security, as the lack of it reduces the time women are able to work in agricultural production and food preparation, reduces disposable income of households, contaminates foods, and causes diarrhea, environmental enteric dysfunction, intestinal worms, and disease, thereby impeding the absorption of nutrients and leading to malnutrition. While consumption of a diverse and nutritious diet rich in micronutrients is critical to improving nutrition and health outcomes, access to and use of improved WASH services is equally important. Regarding sanitation, only 40.6 percent of household members have access to an improved, not shared, sanitation facility.41 WASH behavior change programming is essential to develop demand for both health services and ensure sustained and correct household WASH practices. Considering that 52 percent of Malawi’s current population is below age 18, it is necessary to develop messages that target the youth both in school and out of school. The current burden of disease in Malawi and its associated risk factors clearly indicate a priority for more investment toward household environmental health

38 IFPRI, 2015.

39 Ibid 40 Ibid 41 Ibid

21 | P a g e promotion, and not just health services. Household environmental health includes water, sanitation, hygiene, and indoor air pollution.

C.2.3 Current SBCC Programming in Malawi

C.2.3.1 Coordination of Health SBCC in Malawi The MOH provides oversight of the sector wide health response, and, according to the Health Sector Strategic Plan 2011 – 2016 (HSSP), delivers approximately 60 percent of all health services. At the national level, its various departments and related technical working groups develop national policies, protocols, and guidelines, and define strategic priorities for delivering health services, including health-specific communication priorities.

Within the MOH, the Health Education Section (HES) develops national-level SBCC strategies in conjunction with health units within the GoM, coordinates SBCC across (and beyond) the GoM, designs and produces mass media for national use and designs and produces print materials for national use. HES supports all MOH health departments as the SBCC implementation arm for communications development, and to engage with a range of multi-sectoral public and private partners. HES is also responsible for assisting program implementation in facilities and community settings. However, there is still need for more effective coordination mechanisms within GoM departments and their stakeholders and capacity development around strategic communications design. District Health Education Officers (DHEO) coordinate and implement SBCC interventions in collaboration with District AIDS Coordinators; Information and Youth Officers; frontline workers including Health Surveillance Assistants (HSAs); Community Based Distribution Agents (CBDAs); community-based organizations (CBOs); faith-based organizations (FBOs); and other nongovernmental organizations (NGOs). DHEO are also responsible for adapting and localizing national SBCC strategies and implementing and monitoring outreach and community mobilization associated with health services. DHEO receive training and communication materials from the central level, they are not well capacitated.

SBCC implementation is guided by national policy documents for Essential Health Package (EHP) priorities, and planned and monitored through established mechanisms that bring key partners together. Several program areas also have specifically developed national communication strategies to guide interventions.

The Ministry of Agriculture, Irrigation, and Water Development (MOAIWD), through the National Sanitation and Hygiene Coordination Unit (NSHCU) is responsible for implementing national sanitation and hygiene activities. However, there is a lack of harmonization between existing policies and legal instruments dealing with WASH issues.42 MOAIWD has recently tried to revise overlapping policies but has yet to disseminate them. While some ambiguity exists over the roles and responsibilities of the various stakeholders, including other ministries, the MOH has responsibility for a number of WASH issues, including promotion of hygiene education and prevention of water and sanitation-related diseases.

C.2.3.2 Institutionalization of Health Communications

42 Malawi Government: National Sanitation Policy, December 2008

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Since the 1960s, the MOH has demonstrated commitment to health education and health promotion in all aspects of public health, and, in 1969, established the HES to validate this commitment. During the initial period, the MOH focused on preventive health as health education needs were few and less complex. However, for the past four decades, health education and promotion products and services have become an essential component of the MOH’s strategies for addressing health issues. The current HSSP recognizes health education and promotion as an important component in the delivery of the EHP. To this end, to strengthen the delivery of health education services at district and community levels, DHEO positions were created as part of the MOH staff establishment, and are deployed as part of district health work force.

C.2.3.3 Current Approaches to Health Communications Health communications within the public sector have historically been characterized by a strong emphasis on broad, community-based programming grounded in principles of health education and promotion, such as the Community Conversations Initiative.43 U.S. Government implementing partners and other international and local NGOs have long implemented more targeted SBCC interventions, but have not consistently demonstrated integration across health areas or channels. SBCC interventions are also not always based on state of the art evidence based approaches nor effectively monitored for impact.

Furthermore, the implementation of communications and promotion interventions by different players within the health sector and beyond are not well coordinated, and existing guidelines for activity implementation are limited to the health sector, disregarding other important stakeholders. Additionally, many development professional and policy makers still regard health communications and promotion as the exclusive domain of the health sector, and this presents a challenge considering that determinants of health are multi-sectoral. Even within the health sector, despite the HES mandate, there is still a need for more effective coordination mechanisms within departments; and within primary, secondary, tertiary levels of care and their stakeholders.

Other major challenges include: i) inadequate financial allocation of resources from both government and donors; ii) inadequate numbers of qualified human resources to deliver health communications and promotion activities at central, zonal, district and community levels, which is exacerbated by insufficient health communications positions in the MOH establishment; iii) lack of SBCC standardized modules for training of health workers; iv) limited engagement with the private sector health care providers; and v) non-existence of quality assurance guidelines to implement SBCC activities.

These challenges result in fragmented and inefficient SBCC activities undertaken by various implementing partners and various MOH disease control programs (e.g., malaria, maternal health). Technical assistance is needed to support a more cohesive and multipronged SBCC program and strengthened national leadership.

C.2.3.4 Other SBCC Partners Other major SBCC national partners include the Ministry of Gender; Ministry of Information;

Ministry of Local Government and Rural Development; Ministry of Education Science and

43 http://www.arcrelief.org/site/DocServer/Through_Our_Eyes_Desk_Review--FINAL.pdf?docID=1602

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Technology; Ministry of Youth and Sports Development; Ministry of Agriculture, Irrigation and Water Development (MOAIWD), particularly the Department of Agriculture Extension Services (DAES), which houses nutrition within the ministry; and Ministry of Finance Economic Planning and Development. These ministries, from their technical angle also develop messaging around: water, sanitation and hygiene; health messages in school curriculum including life skills;

nutrition and other general messages. The coordination bodies within the MOH bring together local partners, such as Christian Health Association in Malawi (CHAM), Population Services International, Banja La Mtsogolo (BLM), other NGOs, and in some cases the health care provider private sector – all of which play a critical role in service delivery and SBCC. Key donor organizations including the United Nations Children’s Fund (UNICEF), United Nations Funds for Population Activities (UNFPA), the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), KfW Development Bank (KfW), and the British Department for International Development (DfID) also play an important role in funding and providing technical support to districts in their implementation of SBCC interventions.

C.3 HEALTH-SBCC LINKAGES

C.3.1 Linkages with the GoM and CDCS USAID/Malawi’s CDCS addresses development challenges enunciated by the GoM and the U.S.

Government in a number of critical documents through an integrated approach that concentrates resources programmatically and geographically where and when feasible. (See Annex 1 for summaries of important GoM documents, and Annex 2 for a list of U.S. Government documents.)

Health-SBCC objectives will contribute to the CDCS cross-cutting Sub-Intermediate Result (SIRs) 1: Capacity of institutions improved; SIR2: Policy and systems strengthened; and SIR 3:

Positive behaviors adopted. In addition, as discussed in C.4, the Activity is grounded in several cross-cutting themes, including the integration of gender and youth issues across interventions and capacity building of the institutions that serve women and young people.

C.3.2 Linkage with the Integrated Health Project (IHP) In 2014, in support of the CDCS, the Health Office developed the five-year IHP, which hypothesizes that if health services are improved and effectively used, then the health status of Malawians in the targeted districts will also improve. The Project’s awards and activities, including Health-SBCC, specifically contribute to attaining the CDCS DO 1, which incorporates expanding the availability and quality of essential social services, and posits that by using services more and adopting positive behaviors, Malawians will ultimately become healthier and, hence, more productive.

IHP and its contributions to DO 1 directly support the GoM HSSP’s goal to improve the quality of life of the people of Malawi by reducing the risk of ill health and the occurrence of premature deaths, thereby contributing to the social and economic development of the country. Diagram 1 outlines the Health-SBCC Results Framework and its linkages to CDCS DO 1 and the IHP purpose.

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Diagram 1: USAID/Malawi Health‐ SBCC

Results Framework

CDCS DEVELOPMENT OBJECTIVE 1:

Social Development Improved

HEALTH‐SBCC ACTIVITY PURPOSE:

Demand for quality priority health services increased

IHP PURPOSE

Health status of Malawians in targeted districts improved

IR 4: Improved use of data for decision making in SBCC

IR 3: Capacity of key institutional partners to design, implement, and evaluate high‐quality SBCC improved

IR 2: GoM capacity to lead national SBCC programming improved

IR 1: Health‐seeking practices improved

Cross‐cutting themes:

CDCS integration across activity areas and technical teams

Gender and youth

Innovation

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C.4 HEALTH-SBCC SCOPE OF WORK

The overarching purpose of this activity is to increase demand for quality priority health services and products. This aim directly supports both the IHP purpose to improve the health status of Malawians and the CDCS DO 1: Social Development Improved. Health-SBCC is based on the development hypothesis that: if national capacity is built to design, implement, monitor, and evaluate effective health communications that include the reduction of societal and cultural barriers, then individuals, households, and communities will increase their use of priority health services and positive health practices.

The Activity will strengthen the capacity of the GoM through both shared design and implementation of key national and district SBCC interventions, and focused capacity strengthening efforts and also capacity building of other national partners (particularly ONSE- Athanzi) that implement SBCC interventions at district, community, and household level. The Contractor must support SBCC capacity strengthening by providing public sector capacity strengthening at the national and district levels; capacity strengthening at the individual, institutional, and systems levels; pay attention to both technical and operational capacity; use a range of capacity strengthening approaches (“blended learning”), including training; coaching;

internships/fellowships; shared design and implementation, support for academic programs, and use of formal and proven approaches to measurement of capacity, for purposes of both intervention design and measurement. The Contractor must develop the following competencies at the national level: development of national SBCC strategies; harmonization of SBCC messages; review and approval of SBCC materials and media outputs; review, synthesis, dissemination, and application of emergent research; establishment and…