RMNCAH Activity Special Notice March 2021.pdf

SPECIAL NOTICE

Special Notice Number: SP-621-21-HO-001 Issuance Date: March 29, 2021 POC Email Address: olinuma@usaid.gov and usaidtzco@usaid.gov

PROJECT TITLE: Comprehensive Client-Centered Health Program for Reproductive, Maternal, Newborn, Child And Adolescent Health (C3HP- RMNCAH)

Dear Prospective Offerors:

The United States Agency for International Development (USAID) Mission in Dar es Salaam, Tanzania posts this Special Notice to share an updated Performance Work Statement, draft evaluation criteria and instructions for an upcoming health office activity. The activity will increase the demand for and use of quality integrated RMNCAH services in target regions, particularly women of reproductive age, youth and children, by improving access to quality RMNCAH services in both facilities and the surrounding communities, promoting positive health-seeking behaviors among Tanzania’s population, and enhancing the overall policy environment for RMNCAH service delivery. A five-year activity under a Contract mechanism is anticipated through full and open competition. However, the Government reserves the right to not issue Request for Solicitation for this potential procurement.

Issuance of this Speical Notice does not constitute a Solicitation. It does not represent an award commitment on the part of USAID/Tanzania, nor does it obligate USAID/Tanzania to pay for costs incurred in the preparation and submission of any comments. Feedback received in response to this Special Notice shall become the property of USAID, therefore, information that cannot be shared should not be sent.

The Instructions, Evaluation Criteria and the final Performance Work Statement (PWS) are attached below.

Feedback may be sent to Oddo Linuma at olinuma@usaid.gov with a copy to usaidtzco@usaid.gov.

Please include “SP-621-21-HO-001” in the Subject Line. Respondents will not receive individual feedback. Specific questions about this Special Notice should be directed only to the email addresses indicated above.

Best Regards, Ayana Angulo Contracting Officer USAID/Tanzania mailto:olinuma@usaid.gov mailto:usaidtzco@usaid.gov mailto:olinuma@usaid.gov mailto:usaidtzco@usaid.gov

Attachment 1

COMPREHENSIVE CLIENT-CENTERED HEALTH PROGRAM FOR

REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH

(C3HP- RMNCAH)

PERFORMANCE WORK STATEMENT (PWS)

ACRONYM LIST

ACTs – Artemisinin-based Combination Therapy

AYFHS – Adolescent and Youth Friendly Health Services

ANC – Antenatal Care

ART – Antiretroviral therapy

AQL - Acceptable Quality Level

C3HP – Comprehensive Client-Centered Health Program

CBH & SWP – Community Based Health & Social Welfare Program

CECAP – Cervical Cancer Prevention

CHS – Community Health Strategy

CHW – Community Health Worker

CTC – Care and Treatment Centre.

CQI – Continuous Quality Improvement

CDCS – Country Development Cooperation Strategy

COR – Contract Officer’s Representative

DFID – British Department for International Development

DR-TB – Drug Resistant Tuberculosis

FP – Family Planning

GFATM – Global Fund to Fight AIDS, Tuberculosis and Malaria

GOT – Government of Tanzania

GOZ – Government of Zanzibar

GUC - Grants Under Contract

HPV - Human Papillomavirus

HTI – Health Training Institutions

HIV/AIDS - Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome

HSSP - Health Sector Strategic Plan iCCM – Integrated Community Case Management

IEE – Initial Environmental Examination

IMCI – Integrated Management of Childhood Illnesses

IPTp – Intermittent Preventive Therapy

KMC – Kangaroo Mother Care

LEEP – Loop Electrosurgical Excision Procedure mCPR – Modern Contraceptive Prevalence Rate

MDR– TB – Multidrug-Resistant Tuberculosis

MEL – Monitoring, Evaluation and Learning

MNCH – Maternal, Newborn and Child Health

MNH – Maternal and Newborn Health

MOH – Ministry of Health (Zanzibar)

MOHCDGEC – Ministry of Health and Social Welfare, Elderly and Children (Tanzania Mainland)

NMNAP - National Multisectoral Nutrition Action Plan

NMSF – National Multisectoral Strategic Framework

PEPFAR – U.S. President’s Emergency Plan for AIDS Relief

PMI – U.S. President’s Malaria Initiative

PO-RALG – President’s Office – Regional Administration and Local Government

PPFP - Postpartum Family Planning

PWS – Performance Work Statement

QoC - Quality of Care

RMNCAH – Reproductive, Maternal, Newborn, Child and Adolescent Health

SBC – Social Behavior Change

SDG – Sustainable Development Goal

TB – Tuberculosis

TBD – To be Determined

TDHS – Tanzania Demographic Health Survey

UNAIDS – Joint United Nations Program on HIV/AIDS

USG – United States Government

VIA – Visual Inspection with Acetic Acid

WHO – World Health Organization

I. INTRODUCTION

The purpose of this contract is to implement USAID/Tanzania’s Comprehensive Client-Centered Health Program – Reproductive, Maternal, Newborn, Child and Adolescent Health (C3HP- RMNCAH) activity. Comprehensive Client Centered Health Program (C3HP) is a health care model that is respectful of, and responsive to client’s, families’ and communities’ needs, values, experience and preferences during the planning, coordination and delivery of health care services. USAID/Tanzania intends to support the Government of Tanzania’s (GOT) Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) and the President’s Office-Regional Administration and Local Government (PO-RALG) at the central level and in target Mainland regions as well as the Government of Zanzibar’s (GOZ) Ministry of Health (MOH), their PORALG and other local authorities, to deliver high-quality integrated RMNCAH services that will improve health outcomes, particularly for youth and women.

The acquisition will increase the demand for and use of quality integrated RMNCAH services in target regions, particularly women of reproductive age, youth and children, by improving access to quality RMNCAH services in both facilities and the surrounding communities, promoting positive health-seeking behaviors among Tanzania’s population, and enhancing the overall policy environment for RMNCAH service delivery.

II. ACTIVITY BACKGROUND

1. Global Context

It is estimated that in 2017, 295,000 women around the world died due to complications of pregnancy and childbirth, with major causes including haemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labour. Almost all these deaths occurred in low- and middle-income countries, and almost two thirds in sub-Saharan Africa. Most of these maternal deaths were preventable with appropriate management and care, especially during the preconception, antenatal, labor and delivery periods. In particular, access to basic services such as antenatal care in pregnancy, adequate skilled care during childbirth, and care and support in the first days and weeks after childbirth greatly reduces deaths and influences health outcomes for both mother and child. During the 2012-2017 period, only 59% of births in sub-Saharan Africa were attended by skilled health personnel, while only 52% of pregnant women in sub- Saharan Africa received at least four antenatal visits in 2013-2018.

Maternal health and newborn health are closely linked. While the global under-five mortality rate fell by almost 50% between 2000 and 2017, 5.3 million children still died in 2018 – mainly from preventable causes such as pneumonia, diarrhea and malaria. Almost half of the under-five deaths occurred in the crucial first month of life, with major causes including preterm births, intrapartum-related complications (birth asphyxia or lack of breathing at birth), infections and birth defects.

Preventing unintended pregnancies and reducing adolescent childbearing through universal access to reproductive health care are crucial to the health and well-being of women, children and adolescents. Expanding access to modern contraceptive methods is essential to ensure universal access to reproductive health care. Globally, the proportion of women of reproductive age (15 to 49 years old) who have their need for family planning (FP) satisfied with modern contraceptive methods has continued to increase slowly, from 74 per cent in 2000 to 76 per cent in 2019. However, this is not the same for middle and low income countries where there are missed opportunities for education, some societies still practicing taboos and local customs which to a greater extent increases women vulnerability including missing the opportunity to access reproductive health services. In sub-Saharan Africa, for instance, the levels of adolescent fertility and teenage pregnancy remain high and there is an observed upward trend of these two indicators that shows this is a growing problem in these countries.

In 2015, the member states of the United Nations came together to update international development goals and craft a call to action to end poverty, protect the planet, and improve the lives and prospects of all people, everywhere. Seventeen Sustainable Development Goals (SDG) were adopted and a 15-year plan was developed to achieve the goals by 2030. SDG 3, “Ensure healthy lives and promote well-being for all at all ages,” addresses issues related to RMNCAH, infectious diseases, non-communicable diseases, and health systems.

2. Context in Tanzania

Tanzania’s Vision 2025 of transforming the country from a least-developed economy to a middle-income economy requires high quality human capital and the strengthening of social services, particularly for health and education. In the coming decades, the GOT’s MOHCDGEC and the GOZ’s MOH will play instrumental roles in ensuring that healthy individuals, families, and communities are contributing to the country’s broader socio-economic development. To that end, USAID/Tanzania supports and works in close collaboration with these two entities, their respective PO-RALG bodies, and other local government authorities to improve access to and use of quality health care services for RMNCAH to ensure Tanzania’s citizens are capacitated to live healthy and prosperous lives.

Despite efforts, high rates of maternal, neonatal, and child mortality persist across Tanzania.

Expanded immunization and malaria prevention and treatment programs, along with improved management of common childhood illnesses, helped to reduce the under-five mortality rate from 166 deaths per 1,000 live births in 1990 to 57 deaths in 2017. However, the country still records approximately 270 deaths among children under the age of five years each day, largely from preventable and treatable diseases. Gains in reducing maternal and neonatal deaths have not been as significant as reductions in child deaths. Maternal mortality rates remain high at 556 deaths per 100,000 live births due to challenges such as limited access to quality emergency obstetrics care, untimely referral to emergency obstetric facilities, limited ability of women to independently decide to access health services, limited knowledge and skills among health care workers to manage direct obstetric causes of maternal deaths, including postpartum hemorrhage, that claim more maternal lives than other causes. Neonatal deaths, due to conditions such as asphyxia, prematurity, infection, human immunodeficiency virus (HIV), and malaria, continue to comprise a significant portion of under-five deaths.

Maternal and child health are also negatively impacted by low quality nutrition services and counseling, as well as poor diet and feeding practices, inadequate micronutrient intake. These poor nutrition practices and outcomes may lead to increased morbidity and mortality from infectious diseases such as gastroenteritis, pneumonia, malaria, and measles. Common micronutrient deficiencies, such as a lack of iron, iodine, and vitamin A, also contribute to health issues, particularly during pregnancy, when the body has increased needs. Deficiencies may become particularly common among pregnant women with poorly spaced births. Efforts to improve nutrition are among the most effective interventions to reduce mortality among children and also improve pregnancy outcomes. Ending all forms of malnutrition and addressing the nutritional needs of adolescent girls, pregnant and lactating women, and children is essential for better RMNCAH outcomes.

High fertility rates and low FP use also contribute to maternal, newborn and child deaths in Tanzania. The modern contraceptive prevalence rate (mCPR) among women aged 15-49 in Tanzania has slowly but steadily increased over the past 25 years. According to Tanzania Demographic and Health Surveys (TDHS), the mCPR among currently married women aged 15-49 increased from 7% in 1991/92 to 32% in 2015/16, driven largely by an increase in mCPR in rural areas. Routine data from MOHCDGEC shows the increase in mCPR to 38.6% among the family planning users with regional variation across the country. Despite the gains observed in the past decade, the country will not be able to meet its 2023 mCPR goal of 47% without a well strategized plan in place. The total fertility rate has gradually decreased over the years from an average of 6.2 births per woman in 1991/92 to 5.2 in 2015/16, with rural fertility (6 children per woman) driving the overall high fertility rate in the country compared to the decreasing fertility rates in urban settings (3.8). The country’s unmet need for FP has remained steady at around 22 to 25% over the years. In 2015/16, nearly 40% of married women aged 15- 49 wanted to delay childbearing for at least two years but could not do so. The teenage pregnancy rate in Tanzania declined from 26% in 1999 to 23% in 2010; however, it subsequently increased to 27% in 2015/16 with the highest rate in the regions of Katavi (45%) and Tabora (43%). The rate is 1.7 times higher in rural areas compared to urban areas. It is estimated that in 2015/16, 57% of 19-year old women previously had a live birth or were pregnant with their first child. The situation in Zanzibar is more critical, with a low mCPR of 14%, a high fertility rate of 5.1% and high unmet need for FP of 28% in 2015/16.

Cervical cancer is the leading cause of cancer-related morbidity and mortality among women in Tanzania, with nearly 7,000 women dying each year from this disease. While poor access to screening and treatment services, competing health priorities, insufficient financial resources, weak health systems, limited numbers of trained providers and low coverage are the greatest challenges to addressing this issue, the problem is further magnified by Tanzania’s lack of resources, low coverage of human papillomavirus (HPV) vaccine, sporadic cervical cancer screening services, the prevalence of high-risk oncogenic HPV subtypes, and relatively high rates of HIV co-infection. Despite the above-mentioned challenges, effective methods for early detection of precancerous lesions using visual inspection with acetic acid (VIA) and other methods exist and have shown to be successful in other developing countries.

Improving the quality and coverage of health products and services is not necessarily sufficient to ensure that people use health services and improve health outcomes. Changes in health-https://en.wikipedia.org/wiki/Infectious_diseases https://en.wikipedia.org/wiki/Gastroenteritis https://en.wikipedia.org/wiki/Pneumonia https://en.wikipedia.org/wiki/Malaria https://en.wikipedia.org/wiki/Measles https://en.wikipedia.org/wiki/Iron_deficiency https://en.wikipedia.org/wiki/Iodine_deficiency https://en.wikipedia.org/wiki/Vitamin_A_deficiency https://en.wikipedia.org/wiki/Pregnancy https://en.wikipedia.org/wiki/Nutrition seeking behaviors of individuals and communities, as well as the norms that underpin those behaviors, are also required. For example, in Tanzania, youth are particularly challenged to access and use available health care services due to insufficient knowledge and the negative attitudes, norms, and behaviors of the youth themselves as well as of other health care users, their partners, and influential adults, such as parents, teachers, and health service providers.

Similarly, at the community level, harmful social and gender norms negatively impact health-seeking behaviors and often limit clients’ access to and use of facility- and community-based services.

In Tanzania, multiple behavioral determinants underpin why youth and women of reproductive age fail to access RMNCAH services. Changing this requires addressing behavioral-related factors such as knowledge, attitudes, and inequitable gender norms, including communication between health providers and clients, families’ and couples’ communication, and the engagement of community leaders and other influencers in building trust in the health system and promoting timely use of services, and the adoption of healthy behaviors and practices. Arming communities, families, and healthcare workers with the right skills and information and creating enabling environments that support the empowerment of families, communities and health care workers to improve RMNCAH is essential to maximizing access to and use of quality RMNCAH services to save lives and improve health.

As indicated above, the GOT and GOZ have made significant progress in addressing health concerns across the country, but much remains to be done to enable all Tanzanians to access quality health care services required to live a healthy and productive life. Key constraints include:

Quality of Care Challenges

● Inadequate skilled human resources in the health sector

● Shortages of commodities, medical equipment and supplies

● Inadequate supervision and coaching in health care

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

● Low data quality and inadequate data use for decision-making.

Access Challenges

● Inefficient referral systems and linkages between facilities and communities

● Long waiting time for services at health facilities

● Long distances and difficult terrain

● Limited use of health insurance

● Informal payments at health facilities

Policy/Political-Related Challenges

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

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

● Limited citizen engagement in promoting public sector transparency and accountability

● Inadequate budget allocation and funds disbursement for health

Socio-Cultural Factors

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

The GOT outlined its plans and priorities for the health sector in the MOHCDGEC’s Health Sector Strategic Plan (HSSP) IV (2015-2020) and its forthcoming successor HSSP V; National Road Map Strategic Plan to Improve Reproductive, Maternal, Newborn, Child, and Adolescent Health in Tanzania (2016-2020) (also known as One Plan II) and its forthcoming successor One Plan III; and National FP Costed Implementation Plan (2019-2023). Similarly, the GOZ outlined its plans and priorities for the health sector in the MOH’s Zanzibar HSSP III (2013/14-2018/19) and its forthcoming successor HSSP IV RMNCAH Strategic Plan (2019-2023).

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

Similarly, in 2019 the GOZ launched a new Community Health Strategy (CHS 2019), a follow-on to the strategy launched in 2011. The new strategy, which is under implementation, focuses on national scale up of the community health program in Zanzibar, including revisions of the community health volunteer national training package followed by development of the operational manual.

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

C3HP includes three related activities:

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

● HIV/TB Activities: These two bilateral awards (targeting different regions of the country) will focus on the provision of integrated HIV and TB prevention, care, and treatment services. During implementation, these two awards will integrate HIV and FP interventions as appropriate, and will include community-level SBC interventions.

These three awards will be complemented by a malaria control program and a national social behavior change technical assistance award (a follow-on to the current USAID-supported

Tulonge Afya activity, which ends in 2022). It is envisioned that the three C3HP activities, the malaria control program and Tulonge Afya follow on activities will synergistically collaborate, especially in areas with geographical overlap, to fast track the achievement of the overall goal of improving the health outcomes for all Tanzanians.

I. RELATIONSHIP TO USAID COUNTRY DEVELOPMENT COOPERATION

STRATEGY RESULTS FRAMEWORK

The RMNCAH and HIV/TB activities under C3HP are key to achieving USAID/Tanzania’s tentative, new strategic direction under its draft Country Development Cooperation Strategy (CDCS) for the period 2020-2025, illustrated in Figure 1, below. The draft CDCS focuses on youth (15 - 35 years) as the current and future drivers of Tanzania’s long-term development and prosperity. It emphasizes the needs of youth and young adults for quality public and private sector services that build their skills and productivity, while also focusing on the need for local leadership to create the community environment that allows young people to thrive in a way that will accelerate inclusive, broad-based growth.

Figure 1: USAID/Tanzania Country Development Cooperation Strategy Results Framework, 2020-2025

As shown above, the CDCS posits that IF Tanzania improves the foundational skills of its youth;

empowers and increases the productivity and engagement of young adults; and strengthens the ability of state and non-state actors to benefit future generations, THEN youth will be better positioned to contribute to the long-term prosperity of their country.

Following the CDCS development hypothesis, the C3HP-RMNCAH Activity will support Development Objective DO1, IR1.2 by improving availability and access to RMNCAH services through quality improvements and improved health behaviors; DO2, IR 2.1 by expanding youth access to quality information and supporting youth in taking control of their own health; DO3, IR 3.1, through mentoring, training, supportive supervision and capacity-building at various levels of the health system; and DO3, IR3.3 through strengthening linkages between health facilities and communities.

II. SCOPE OF WORK

Under the C3HP-RMNCAH activity, USAID/Tanzania seeks increased use of, demand for and access to quality integrated RMNCAH services, particularly by youth and women, leading to improved health outcomes.

To accomplish this, the Contractor must provide technical and material assistance and/or administrative and management support to the GOZ-MOH and the GOT-MOHCDGEC and PO-RALG entities, to local government authorities (district and council levels), and to health facilities to increase their capacity to manage and deliver quality RMNCAH services within the public health sector. The Contractor must also provide technical and material support to strengthen the provision of community-based health services and improve linkages between communities and health facilities. The C3HP-RMNCAH Contractor must support a set of smartly integrated RMNCAH interventions that include routine and outreach FP services, MNCAH and cervical cancer prevention (CECAP) services. In addition, the Contractor must promote social behavior change that addresses knowledge gaps, attitudes, negative social/gender norms and other barriers to using health services, thus promoting positive health-seeking behaviors, particularly for youth and women. Finally, the Contractor must support national level efforts to update and operationalize policies, procedures and guidelines related to RMNCAH services provision, including citizen involvement during their development and implementation.

The Contractor must provide these services in Zanzibar and targeted regions of Tanzania Mainland, as discussed in the section below entitled “Geographic Coverage.” The services provided, as well as the intensity required, will be determined by the Contractor in consultation with the GOT and USAID/Tanzania during annual work plan development and are expected to evolve from year to year throughout the period of performance based on needs represented by the evolving data and the availability of funds.

All C3HP-RMNCAH work implemented on Tanzania Mainland under this award must be guided by the MOHCDGEC’s National Road Map Strategic Plan to Improve Reproductive, Maternal, Newborn, Child, and Adolescent Health in Tanzania (2016-2020) (also known as One Plan II) and its forthcoming successor One Plan III, the recently launched National FP Costed Implementation Plan (2019-2023), the Community Based Health and Social Welfare Program (CBH & SWP) policy and operational guidelines, the National Multisectoral Nutrition Action Plan (NMNAP 2016-2021), National Operational Guideline for Community Based Health Care Services (2020), Quality Improvement Framework (2020-2025), National Guideline for Gender and Respectful Care Mainstreaming and Integration Across RMNCAH Services in Tanzania (2019), the Health Sector Strategic Plan IV (HSSP IV) (2016-2020) and HSSP V under development. Similarly, all interventions under this award that will be implemented in Zanzibar must be guided by MOH’s Zanzibar Health Sector Strategic Plan III (2013/14-2018/19) and its forthcoming successor HSSP IV; Zanzibar RMNCAH Strategic Plan

(2019-2023), and the Zanzibar Community Health Strategy.

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

Figure 2: C3HP-RMNCAH Activity Results Framework

C3HP-RMNCAH ACTIVITY DEVELOPMENT HYPOTHESIS:

IF: (1) Beneficiaries, particularly women, youth and children, have access to quality integrated RMNCAH services in facilities and communities that are linked to ensure a continuum of care;

and IF: (2) equitable social/gender norms and practices that facilitate positive health-seeking behaviors are strengthened; and IF: (3) the right policies are in place and clients are engaged in service delivery; THEN Tanzanians, especially women and youth, will use the integrated RMNCAH services, leading to healthier lives and thriving communities.

Geographic Coverage

As indicated in the map below, the C3HP-RMNCAH Activity will focus on both MNCAH and FP in Zanzibar and five regions of Tanzania Mainland:

Geita, Simiyu, Mwanza, Mara and Shinyanga. In the regions of Manyara, Katavi and Dodoma, the focus will be only on MNCH. FP will be the only focus in the regions of Tabora, Tanga and Dar es Salaam.

Target regions for support were identified based on health statistics and performance against RMNCAH indicators (i.e. low composite rates of antenatal care (ANC) early visits, four ANC visits, institutional deliveries, two doses of intermittent preventive treatment (IPT2), child immunizations, and mCPR, along with high teenage pregnancy rates, unmet need for modern contraception, etc.), as documented in the most recent TDHS and other GOT documents, and will be confirmed by USAID after consultation with the GOT and GOZ. The expected intervention focus by region is stated, however, should needs/priorities evolve, MNCH and FP interventions may be implemented in any of the mentioned Tanzania Mainland regions and Zanzibar. To improve health outcomes and ensure that services are client-centered, when and where it makes sense, the Contractor must integrate MNCAH and FP services in the regions where both interventions are supported. The contractor must advocate for integration of MNCAH and FP services in regions where only one package of intervention is supported by this award. Further, the contractor must closely work with local government authorities in the supported regions to prioritize health facilities that the award can support mainly among public and faith-based facilities for higher RMNCAH outcomes and impact.

Ensuring client-centered health services also requires working collaboratively with activities beyond those supported by C3HP-RMNCAH. Section VII of this PWS discusses USAID’s requirements for collaboration with other USAID-supported activities as well as collaboration with activities supported by other development partners.

III. RESULT AREAS

It is anticipated that the C3HP-RMNCAH Award will contribute to the results framework as outlined in the following discussion:

Intermediate Result 1: Improved access to quality, client centered RMNCAH services

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

● Sub IR 1.2 – Improved access to quality health services at the community level

● Sub IR 1.3 –Strengthened linkages between facility and community health services

Improved access to and use of quality, client-centered health care at both the facility and community levels is essential to improving health outcomes in the targeted regions. Depending on the context and part of the country, access to quality RMNCAH services, especially in the public sector, is affected differently by the various dimensions of access (physical accessibility, financial accessibility, and acceptability of services). Under the C3HP RMNCAH activity, the Contractor must collaborate with key stakeholders, including the GOT/GOZ at all levels, to focus on mitigating factors related to physical access and acceptability of services. The Contractor must ensure there is a continuum of care by addressing quality challenges to facility-and community-based RMNCAH care in the supported regions and by strengthening linkages between the supported health facilities and the communities they serve. Where feasible and possible, the Contractor must integrate provision of RMNCAH services and employ gender transformative approaches to make them more client centered. In addition, the Contractor must coordinate with other USAID activities working in the same regions that focus on addressing financial challenges to access.

Mandatory Result Annual Performance Standard

Increased access to integrated client centered RMNCAH services

● 10% annual increase in number of women, youth, newborn and children in targeted regions accessing RMNCAH services.

Sub IR 1.1 – Improved access to quality health services at the facility level

The health system is challenged to deliver the quality integrated health services required to save lives and reduce morbidity and mortality, particularly among newborns, children, adolescents and women. Access to quality integrated health services is particularly a challenge in rural areas, where, at the facility level, shortages of skilled health care staff, inadequate supervision and motivation, poor infrastructure, a shortage of medical equipment and supplies, and insufficient referral systems are most acute. Further, services are not always provided in a respectful and/or adolescent-friendly manner. This makes access to quality RMNCAH care even more difficult for beneficiaries hence highlighting the importance of outreach services to surrounding communities. Urban populations also face a number of barriers to accessing RMNCAH services, including direct and indirect costs that clients have to incur at health facilities as a result of low use of health insurance and disproportionately low availability of skilled workforce in relation to the urban population.

With the significant shortage of skilled human resources, there is a need to deliver RMNCAH services that are of high quality, “smartly integrated” and friendly, especially to adolescents.

“Smart integration” refers to provision of a combined set of interventions at logical service delivery points where services are most effectively accessed and delivered to beneficiaries.

Smartly integrated health services have the potential to respond to barriers in accessing RMNCAH services in the country. As several studies have revealed, integration of services in a one - stop model increases client satisfaction with service delivery, reduces costs associated with travel and reduces the workload of the available workforce at health facilities. The Contractor must use this approach to improve access to quality RMNCAH care.

Expected Results:

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

Outcome Mandatory Results

Annual Performance Standard AQL*

1.1.1

Improved access to quality maternal and newborn health services

Targeted health facilities provide comprehensive ANC services according to GOT/GOZ guidelines o 20% increase in ANC first visits before 12 weeks of gestation age o 10% increase in ANC clients who received iron/folic acid o 30% increase in ANC clients screened for syphilis who were treated o 20% increase in ANC clients reached by nutrition-specific interventions o 20% increase in ANC clients that received IPTp3+ o 20% increase in ANC clients that attended the required number of ANC visits.

80% of standard

Targeted health facilities provide emergency obstetrics and newborn care according to GOT/GOZ guidelines o 20% increase in premature babies received kangaroo mother care o 20% increase in newborns resuscitation following breathing challenges at birth o 20% increase in newborns breastfed within the first hour.

o 20% increase in Utilization of labor and delivery services o 10% increase in the number of women that received uterotonic for the third stage of labor.

o 20% decrease in the case fatality rate from direct obstetrics causes o 20% decrease in the number of fresh stillbirths

80% of standard

Annual Performance Standard AQL* o 15% increase in number of post-partum women seeking postnatal care within 48 hours.

o 20% increase in the number of Caretakers who seek appropriate care for signs and symptoms of common newborn illnesses

1.1.2

Improved quality of child health services

Children under the age of five years receive care as per the national guidelines and standards.

o 20% increase in children under 5 years that are correctly assessed and treated using the integrated management of common childhood illnesses (IMCI) algorithm o 5% increase in children receiving age-appropriate immunizations services

90% of standard

1.1.3

Improved quality of adolescent and youth health care services

Targeted facilities provide youth and adolescent friendly health services (AYFHS) for RMNCAH services o 20% increase in uptake of RMNCAH services among youth and adolescents.

o 20% increase in health workforce that can provide AYFHS at community and facility levels.

80% of standard

1.1.4

Improved quality of family planning services

Uptake of a broad range of contraceptive services based on volunteerism and informed choice in targeted health facilities.

o 15% increase in uptake of FP services by age categories 15-19, 20-24 and 25+ years.

o 15% increase in modern FP uptake by type of contraception (implants, pills condom etc).

Annual Performance Standard AQL*

Service delivery points offer integrated family planning services in targeted facilities.

o 20% increase in uptake of FP among postpartum clients o 10% increase in uptake of FP among post abortion clients o 20% increase in uptake of FP among PLHIV in PEPFAR-supported sites o 20% increase in number of clients counselled and referred for FP.

80% of standard

1.1.5

Improved quality of

CECAP

services

Service delivery points offer integrated CECAP services in targeted facilities according to national guidelines.

o 20% increase in the number of clients screened for cervical cancer by age categories.

o 30% increase in treated clients with precancerous lesions after screening.

o 10% increase in referred clients with confirmed cervical cancer.

* For example, an AQL of 80% for a standard requiring 20% achievement means 16% of achievement is acceptable.

Sub IR 1.2 – Improved access to quality health services at the community level

To ensure that key RMNCAH interventions and approaches are equitable, relevant and acceptable to local communities, it is critical to understand and address barriers to demand for and access to health services. When appropriately designed and implemented, community health worker (CHW) programs play an important role in reducing inequitable access to services by bringing information, services, and supplies to women and men in the communities where they live and work rather than requiring them to visit health facilities. CHWs can be particularly successful in increasing the use of contraception, especially where unmet needs are high, access is low, and geographic or social barriers to the use of RMNCAH services exist. CHWs can also perform case management and recognize key danger signs in maternal and child health, boosting referral systems and supporting timely care-seeking behaviors. CHW can also play a key role in promoting good nutrition for pregnant women, ensuring deliveries are assisted by a skilled attendant in a health facility, carrying out postnatal home visits of mothers and their newborn babies, etc.

In Tanzania, the services offered by community health workers are limited and CHW do not always have the training or supplies/equipment needed to perform their services. There is no well-established system to coordinate and standardize the work done by CHWs operating indifferent communities in the country, greatly affecting the impact of their work.

To address these issues, the GOT is rolling out the Community Based Health and Social Welfare Program and transitioning the community case workers and volunteers into a formal CHW program aligned with the Policy Guidelines for Community Based Health and Social Welfare Services, 2020, and the National Operational Guidelines for Community Based Health Care Services, 2020. In Zanzibar, the GOZ-MOH is scaling up its Community Health Program and strengthening CHW human resource management and pre-service and on-the-job training for

CHW.

Expected Results: To achieve this sub-IR, the Contractor must improve the quality of RMNCAH-related health services delivered at the community level.

Outcome Mandatory Results Annual Performance Standard

AQL*

1.2.1

Improved community-based maternal and newborn care

Targeted communities have access to maternal and newborn care services as per the national guidelines and standards o 15% increase in pregnant women attending ANC first visits before 12 weeks of gestation age o 20% increase in clients that attended the required number of ANC visits o 20% increase in postpartum care attendance for women and their newborn.

o 20% increase in caretakers who seek appropriate care for signs and symptoms of newborn illnesses o 20% increase in clients receiving MNH and nutrition information, referrals, and/or services.

80% of stand ard

1.2.2

Improved community level child health services

Children have access to community-based child health services as per the national guidelines and standards in the targeted communities o 10% increase in children that received age-appropriate immunization services o 15% increase in children that received iCCM services o 20% increase in children reached through community-level nutrition interventions

90% of stand ard

1.2.3

Improved community level adolescent and youth health services

Targeted communities are able to identify the adolescent and youth RMNCAH needs and provide appropriate services and/or referrals as per the national guideline.

o 20% increase in adolescents and youth with identified RMNCAH needs who received services and /or a referral o 20% increase in uptake of RMNCAH services among adolescents and youth.

80% of stand ard

* For example, an AQL of 80% for a standard requiring 20% achievement means 16% of achievement is acceptable.

Sub IR 1.3 – Strengthened linkages between facility and community health services

Poor linkages between health facilities and communities further impact the continuum of RMNCAH care and contribute to the country’s high maternal, neonatal and child mortality rates.

Furthermore, harmful social and gender norms in many communities negatively impact health-seeking behavior, often limiting clients’ access to and use of facility- and community-based services.

An operationalized approach that facilitates community/facility linkages and fosters an effective referral system and ensures a continuum of RMNCAH care from the facility to the community and vice versa is needed. Such an approach also helps to promote functional collaboration between all levels of the health systems, ensuring that clients receive the best possible quality RMNCAH care and services on time and at the appropriate health facility level. Studies indicate that child mortality declines when an integrated management of newborn and childhood illnesses (IMCI) strategy is implemented in both health facilities and communities. Also, integrated community case management (iCCM) proves to be an important strategy for extending care to the community level in countries where access to health facilities is poor.

Expected Results:

To achieve this result, the Contractor must facilitate community/facility linkages to ensure a continuum of quality RMNCAH care.

Outcome Mandatory Results Annual Performance Standard

AQL*

1.3 Improved

linkages between facilities and communities

Targeted beneficiaries by age categories who received RMNCAH services in supported health facilities and communities as per the national guidelines..

o 15% increase in clients attending required number of ANC visits o 20% increase in uptake of postpartum care services for women and their newborn.

o 20% increase in caretakers who seek appropriate care for signs and symptoms of newborn illnesses o 20% increase in children receiving age-appropriate health care services o 20% increase in utilization of RMNCAH services among Adolescents and youth in the supported regions.

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

● Sub IR 2.1 – Improved determinants of priority health behaviors related to health-seeking behavior

● Sub IR 2.2 – Improved positive community gender norms and support for health behaviors among the targeted population

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

SBC interventions complement and enhance improvements to health service delivery by addressing barriers to accessing these services and by enhancing interactions between health providers and clients. Findings from the Tulonge Afya Tulonge Afya Midterm Evaluation report show that the activity was successful in improving health seeking behaviors across the priority https://pdf.usaid.gov/pdf_docs/PA00WRZ7.pdf health areas, including, but not limited to, increased use of condoms, modern FP methods, HIV testing services, and insecticide treated bed nets; increased delivery in clinics; and increased ANC visits. For greater impact, the midterm evaluation recommended stronger linkages and coordination between SBC and service delivery interventions at the community level.

The C3HP-RMNCAH activity builds on the successes and recommendations of the Tulonge Afya activity. The Contractor must leverage Tanzanian social and behavior change expertise f to implement a comprehensive package of evidence-based SBC interventions at the community level. Interventions must be appropriately tailored to the targeted communities and populations (i.e. by gender, age, etc.).

Mandatory Result Annual Performance Standard Improved ability of individuals to practice positive health-seeking and self-care behaviors

● At least 20% of the targeted population utilizing RMNCAH services at the facility or community level recall hearing or seeing RMNCAH specific messages or products in the supported regions.

Sub IR 2.1 – Improved determinants of priority health behaviors related to health-seeking behavior

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

To address this concern, the Contractor must implement a robust program of SBC interventions at the health facility and community levels that builds individuals’ ability and motivation to access services, improves provider behaviors to enhance client satisfaction and the client-provider relationship, and boosts continuation and maintenance of positive health behaviors. The Contractor must adopt innovative SBC approaches that are evidence- based and employ current innovations in behavioral sciences to address behavioral determinants comprehensively across the health service delivery continuum. Moreover, the Contractor must employ data-driven and audience segmentation that accounts for demographic, attitudinal, and behavioral factors during design and implementation of SBC interventions.

Expected Results:

The Contractor must strengthen coordination and increase coverage of integrated SBC interventions at the regional and district levels, leading to increased and continued use of RMNCAH services by clients and timely follow up for RMNCAH needs.

Performance Standard AQL*

2.1

Improved health-seeking behaviors in target communitie s

Targeted communities and facilities implementing effective and evidence-based SBC interventions on RMNCAH in the supported regions o 20% increase in number of SBC materials for RMNCAH services printed and disseminated in the supported regions o 20% increase in mobile applications use as SBC platform for RMNCAH services in the supported regions.

o 20% increase in number of times RMNCAH messages were aired on television or radio in the supported communities.

o 20% increase in number of people reached with targeted SBC interactions on RMNCAH.

80% of standard

Sub IR 2.2 – Improved positive community gender norms and support for healthy behaviors among targeted population The different way men and women are socialized and how they are expected to behave by society poses a structural barrier to the utilization of RMNCAH services. Evidence based, scalable normative interventions have the potential to create, transform, and reinforce positive social norms. Given the important role men play in decision-making in Tanzania, effective male engagement approaches are of particular relevance.

Expected Results:

The Contractor must implement gender transformative SBC interventions that address inequalities in service utilization, especially among youth.

Outcome Mandatory Results Annual Performance Standard AQL*

2.2.1

Improved positive gender norms for

RMNCAH

services uptake

Targeted communities implementing RMNCAH gender transformative approaches in the supported regions.

o 15% increase in number of community members participating in community-level activities for RMNCAH (e.g., community dialogues, support groups, commodity distribution) disaggregated by geographic area, sex in supported regions.

o 20% increase in number of couples/partners reached with gender interventions in supported communities.

o 20% increase in the number of men reached with gender interventions disaggregated by age in the supported communities.

Intermediate Result 3: Enhanced enabling environment for quality RMNCAH service provision

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

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

Tanzania has in place a broad foundation of strategies, guidelines and standard operating procedures that inform RMNCAH programming in the country. Building on the past and existing National guidelines and standards, the Contractor must work in collaboration with all RMNCAH stakeholders to ensure the availability and operationalization of up- to- date guidelines and standards that are informed by the best and up- to- date globally known scientific evidence.

Operationalizatio…