SOL-306-14-000086.pdf

Issuance Date: September 30, 2014 Deadline for Questions: October 8, 2014, 17:00, Eastern Time (U.S) Closing Date: November 5, 2014, 17:00, Eastern Time (U.S)

Subject: Solicitation SOL-306-14-000086 - Health Sector Resiliency Project USAID/Afghanistan.

To All Prospective Offerors:

The United States Government, represented by the U.S. Agency for International Development (USAID), is seeking proposals from qualified organizations to implement one of USAID/Afghanistan’s flagship Health Program. The purpose of this program is to assist the Government of the Islamic Republic of Afghanistan (GIRoA) and the Ministry of Public Health

(MoPH) to implement critical sector-wide reforms required to make the health system more resilient and sustainable and reliant on domestic resources, as described in Section C of the attached Request for Proposals (RFP).

USAID/Afghanistan anticipates awarding one cost reimbursement completion-type contract as a result of this solicitation covering an estimated period of five (5) years, subject to availability of funds and demonstration of successful performance.

Offerors must propose costs that they believe are realistic and reasonable for the work described herein. The estimated cost range for this procurement is between $30 Million and $40 Million.

This procurement will be conducted under full and open competition procedures, pursuant to Part 15 of the Federal

Acquisition Regulation (FAR) (48 CFR Chapter 1). If your organization decides to submit a proposal in response to this solicitation, it must be submitted in accordance with Section L of this RFP. Offerors must also carefully review Section M -

Evaluation Factors for Award. Sections B through I of the solicitation will become a substantive part of the anticipated contract with blanks to be completed by the Contracting Officer upon award.

USAID encourages participation to the maximum extent possible of small business concerns, veteran owned small businesses, service-disabled veteran small businesses, HUBZone small businesses, small disadvantaged businesses, and women-owned small businesses in this activity as the prime Contractor or as subcontractors, as well as local or regional organizations, or other teaming arrangements in accordance with one of the key areas of USAID FORWARD.

It is the responsibility of the recipient of this solicitation to ensure that the solicitation has been received from the Federal

Business Opportunities (FedBizOpps) website in its entirety. USAID bears no responsibility for data errors resulting from download or conversion processes.

An Interested Vendor List is not included in this solicitation. Offerors can register and use the Interested Vendor List (IVL) on the Federal Business Opportunities (FedBizOpps) website. This is a useful tool so that firms can contact one another for consideration of teaming arrangements and/or small business subcontracting opportunities in response to this solicitation

Proposals must be signed by an official who is authorized to bind the offeror’s organization. All proposals in response to this solicitation will remain available for acceptance by USAID for a minimum of one hundred and eighty (180) calendar days.

Proposals must be submitted by the designated date and time indicated in Block 9 of the RFP cover page (Standard Form 33).

Proposals received after the closing date and time will be processed as late and handled in accordance with FAR 15.208.

Any questions regarding this RFP are to be submitted in writing to the following e-mail address:

kabulaidoaamailbox@usaid.gov, by the date and time specified above. Oral instructions or explanations given before the award of the contract resulting from this solicitation will not be binding. Answers to all offerors’ questions will be provided mailto:kabulaidoaamailbox@usaid.gov

SOLICITATION, OFFER AND AWARD 1. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 CFR 7900)

RATING PAGE OF PAGES

2. CONTRACT NUMBER 3. SOLICITATION NUMBER 4. TYPE OF SOLICITATION 5. DATE ISSUED 6. REQUISITION/PURCHASE NUMBER

CODE7. ISSUED BY 8. ADDRESS OFFER TO (If other than item 7)

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

SOLICITATION

9. Sealed offers in original and copies for furnishings the supplies or services in the Schedule will be received at the place specified in item 8, or if hand carried, in the depository located in until local time

CAUTION - LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

10. FOR

INFORMATION

CALL:

A. NAME B. TELEPHONE (NO COLLECT CALLS)

AREA CODE NUMBER EXT.

C. E-MAIL ADDRESS

11. TABLE OF CONTENTS

(X) SEC. DESCRIPTION PAGE(S) (X) SEC. PAGE(S)DESCRIPTION

A B C D E F G H

I

J

K

L

M EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND OTHER

STATEMENTS OF OFFERORS

PART IV - REPRESENTATIONS AND INSTRUCTIONS

LIST OF ATTACHMENTS

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

CONTRACT CLAUSESSOLICITATION/CONTRACT FORM

SUPPLIES OR SERVICES AND PRICES/COSTS

DESCRIPTION/SPECS./WORK STATEMENT

PACKAGING AND MARKING

INSPECTION AND ACCEPTANCE

DELIVERIES OR PERFORMANCE

CONTRACT ADMINISTRATION DATA

SPECIAL CONTRACT REQUIREMENTS

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

12. In compliance with the above, the undersigned agrees, if this offer is accepted within calendar days (60 calendar days unless a different period is inserted by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

13. DISCOUNT FOR PROMPT PAYMENT

(See Section I, Clause No. 52.232-8)

14. ACKNOWLEDGMENT OF AMENDMENTS

(The offeror acknowledges receipt of amendments to the SOLICITATION for offerors and related documents numbered and dated):

10 CALENDAR DAYS (%) 20 CALENDAR DAYS (%) 30 CALENDAR DAYS (%) CALENDAR DAYS(%)

DATEAMENDMENT NO.AMENDMENT NO. DATE

15A. NAME AND

ADDRESS

OF OFFER-

OR

CODE FACILITY 16. NAME AND THE TITLE OF PERSON AUTHORIZED TO SIGN OFFER

(Type or print)

15B. TELEPHONE NUMBER

AREA CODE NUMBER EXT.

15C. CHECK IF REMITTANCE ADDRESS IS

DIFFERENT FROM ABOVE - ENTER SUCH

ADDRESS IN SCHEDULE.

17. SIGNATURE 18. OFFER DATE

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEMS 20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL OPEN COMPETITION:

10 U.S.C. 2304 (c) 41 U.S.C. 253 (c)

24. ADMINISTERED BY (If other than Item 7)

26. NAME OF CONTRACTING OFFICER (Type or print)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

25. PAYMENT WILL BE MADE BY

27. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

28. AWARD DATE

CODE

ITEM

STANDARD FORM 33 (REV,. 9-97)

Prescribed by GSA - Far (48 CFR) 53.214 (c)

SEALED BID (IFB)

NEGOTIATED (RFP)

(Hour) (Date)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

PART I – THE SCHEDULE

SECTION B - SUPPLIES OR SERVICES AND PRICES/COSTS

B.1 PURPOSE

The objective of the Health Sector Resiliency Project is to support GIRoA, to foster a strengthened, reformed and increasingly self-reliant Afghan health system prepared for the decreased donor support anticipated over the coming decade. The HSR Project will act as a resource and a catalyst to the MoPH and other GIRoA entities as it considers and implements critical sector-wide reforms that will be required to make the system more resilient and sustainable and reliant on domestic resources. As government reform must be an internally-led process, the MoPH will take the lead in all project activities, while the Project serves as a key technical advisor and resource to the MoPH to address the need for increased efficiencies, sustainability, and continued gains in health for all Afghans

B.2 ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT

(a) The estimated cost for the performance of the work required hereunder, exclusive of fixed fee, if any, is

$TBD. The fixed fee, if any, is $TBD and the estimated cost plus all fixed fee, if any, is $TBD.

(b) Within the estimated cost plus all possible fee (if any) specified in paragraph (a) above, the amount currently obligated and available for reimbursement of allowable and allocable costs incurred by the Contractor (and payment of fee, if any and in accordance with Section B.7 below) for performance hereunder is $ TBD. The

Contractor must not exceed the aforesaid obligated amount.

(c) Funds obligated hereunder are anticipated to be sufficient through TBD.

B.3 CONTRACT BUDGET

As the period of performance for this contract is five (5) years, the CLIN budget structure is broken out into five, one-year increments, as follows:

CLIN

No.

CLIN DESCRIPTION Year 1 Year 2 Year 3 Year 4 Year 5 Total

0001 Improved health sector governance and accountability

0002 Increased domestic financing for priority health services.

0003 Strengthened MoPH human resources systems and operations.

0004 Grants Under Contract

(GUC)

$ $- $- $- $- $4,000,000

0005 Security $- $- $- $- $- $-

Sub- Total $- $- $- $- $- $-

0006 Fixed Fee $- $- $- $- $- $-

Total CPFF $- $- $- $- $- $-

B.4 INDIRECT COSTS

For the Prime Contractor:

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

Description Rate Base Type Period

TBD 1/ 1/ 1/

1/Base of Application:

Type of Rate: Predetermined Period:

For Major Subcontractor(s)*

* “Major subcontractor(s)” are those subcontractors whose costs exceed 15 percent of the contract value or who are otherwise defined by the prime to be essential to successful project implementation. All primes MUST identify

“major subcontractors” in the cover letter of their proposals.

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

Description Rate Base Type Period

TBD 1/ 1/ 1/

1/Base of Application:

Type of Rate: Predetermined Period:

B.5 ADVANCE UNDERSTANDING ON CEILING ON INDIRECT COST RATES AND FINAL

PERFORMANCE FOR INDIRECT COSTS

(a) For each of the Contractor's accounting periods during the term of this contract, the parties agree as follows:

(1) The distribution base for establishment of final [rate 1 description to be inserted] is [to be inserted at award].

(2) The distribution base for establishment of final [rate 2 description to be inserted] is [to be inserted at award].

(3)The distribution base for establishment of final [rate 3 description to be inserted] is [to be inserted at award].

(b) The Contractor will make no change in its established method of classifying or allocating indirect costs without the prior written approval of the contracting officer.

(c) Reimbursement for indirect costs will be at the final negotiated rates, but not in excess of the following ceiling rates:

Description 2015 2016 2017 2018 2019 [Rate 1 description to be inserted] __% ___% ___% ___% ___% [Rate 2 description to be inserted] __% ___% ___% ___% ___% [Rate 3 description to be inserted] __% ___% ___% ___% ___%

(d) The government will not be obligated to pay any additional amount on account of indirect costs above the ceiling rates established in the contract. This advance understanding will not change any monetary ceiling, cost limitation, or obligation established in the contract.

B.6 COST REIMBURSABLE

Allowable costs will 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.

B.7 FEE SCHEDULE

Pursuant to FAR 16.306 (d), the fixed fee payable under this contract will be tied to the completion of the reports and deliverables specified in Section C and Section F of this contract and in accordance with approved Fee Schedule below (if any).

Deliverables: The fee payments will be determined according to the following Fee Schedule. In numbering deliverables, the first three digits of the numbering convention is the CLIN/objective of the program; the number that follows is the year and the last number is the number of the deliverable for that component. E.g., 001.1.2 is

CLIN/Objective 001, Year 1, and Deliverable Number 2.

[The following is an illustrative table which will be filled in at time of award]

B.8 CANCELLATION CEILING

In the event that the Government cancels requirements for services in subsequent program years under this contract, the following conditions will apply: [Amount and dates to be filled in at time of award]

CLINS 001 thru 005 are 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 2: DATE TBD, 2016

YEAR/DELIVERABLES Completion

Date

Percent

Fixed Fee

Amount of

Fixed Fee

CLIN 0001: Improved health sector governance and accountability

Deliverable 001.1.1 % $ -

Deliverable 001.1.2 % $ -

Deliverable 001.1.3 % $ -

Deliverable 001.1.4 % $ -

CLIN 0002: Increased domestic financing for priority health services.

Deliverable 002.1.1 % $ -

Deliverable 002.1.2 % $ -

Deliverable 002.1.3 % $ -

Deliverable 002.1.4 % $ -

CLIN0 0003: Strengthened MoPH human resources systems and operations.

Deliverable 003.1.1 % $ -

Deliverable 003.1.2 % $ -

Deliverable 003.1.3 % $ -

Deliverable 003.1.4 % $ -

CLIN 0004: Grants Under Contract (GUC)

Manual

Total

Contract Year 3: DATE TBD, 2017

Contract Year 4: DATE TBD, 2018

Contract Year 5: DATE TBD, 2019

Cancellation Ceiling:

This is a CPFF 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. Therefore, the cancellation ceiling for each cancellation date is [negotiated amount].

[END OF SECTION B]

SECTION C - DESCRIPTION/SPECS./WORK STATEMENT

ABBREVIATIONS / ACRONYMS

ANDS Afghan National Development Strategy AHS Afghan Health Survey AMS Afghanistan Mortality Survey ANMSO Afghanistan National Medical Services Organization APHA Afghanistan Private Hospitals Association AusAid Australian Agency for International Development BPHS Basic Package of Health Services CHW Community Health Worker CIDA Canadian International Development Agency CME Continuing medical education CBR Capacity Building for Results CSO Civil Society Organization DHO District Health Office DO Development objective DPSC Directorate of Private Sector Coordination EPHS Essential Package of Hospital Services EU European Union FP/MNCH Family Planning/Maternal, Newborn and Child Health FY Fiscal year GAVI Global Alliance for Vaccines and Immunization GCMU Grants and Contracts Management Unit GDMA General Directorate of Municipal Affairs GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GIRoA Government of the Islamic Republic of Afghanistan HIS Health information system HRH Human resources for health HSR Health Sector Resiliency HSS Health systems strengthening IDLG Independent Directorate of Local Governance IR Intermediate result ISLA Initiative to Strengthen Local Administrations IST In-service training LOE Level of effort MAB Municipal Advisory Boards M&E Monitoring and evaluation mHealth Mobile health MICS Multiple Indicator Cluster Survey MOF Ministry of Finance MOJ Ministry of Justice MoPH Ministry of Public Health MP Member of Parliament NGO Non-governmental organization NPP National Priority Program NRVA National Risk and Vulnerability Assessment PBI Provincial Budgeting Initiative PHCC Provincial Health Coordination Committee PHO Provincial Heath Office PLD Provincial Liaison Directorate PMP Performance management plan PR Program Result RBF Results-based financing

SEHAT System Enhancement for Health Actions in Transition SHAHAR Strong Hubs for Afghan Hope and Resilience TBD To be determined UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States government WHO World Health Organization

TITLE: HEALTH SECTOR RESILIENCY (HSR)

C.1 EXECUTIVE SUMMARY

The USAID Health Sector Resiliency (HSR) Project will act as a resource and a catalyst to support the Ministry of

Public Health (MoPH) to implement critical sector-wide reforms that will be required to increase the resiliency and self-sufficiency of the health sector and move towards sustainability. Understanding that reform must be an internally-led process, the MoPH will lead all project activities, while the Contractor serves as a key technical advisor and resource to the MoPH, other GIRoA entities and the private sector to address the need for increased efficiencies, sustainability, and continued gains in health for all Afghans. It is anticipated that as the sector matures and the donor landscape shifts, the needs and circumstances of the MoPH will change; the HSR Project must be responsive, innovative and flexible to adapt to this fluctuating environment.

The HSR Project will primarily focus on governance, finance and human resources and will engage both the public and private components of the health sector. The project will support the MoPH to strengthen and reform its systems at both central and subnational levels, applying and adapting relevant international best practices to support the MoPH to successfully navigate this upcoming transition period. The HSR Project will also include a robust learning agenda to guide project implementation and to determine the impact of systems strengthening and reform activities and their impact on health status.

C.2 BACKGROUND AND CONTEXT

C.2.1 Transition and Transformation

Facing international military drawdown and declining donor assistance, Afghanistan is transitioning to a period characterized by greater Afghan ownership of security and development objectives beginning with the current transition year (2014) and lasting through the Transformation Decade (2015-2024).

Since the fall of the Taliban, there have been significant successes as a result of GIRoA stewardship and donor assistance but despite such progress, much remains to be done. Instability persists throughout the country and confidence in GIRoA is fragile. Over this period of the Transformation Decade, GIRoA will have to take the principal role in addressing the development challenges in Afghanistan. The challenge moving forward is to strengthen GIRoA’s capacity to continue achievements realized over the past decade years.

GIRoA’s ability to provide services to the population effectively, especially in health and education, is crucial for the government’s legitimacy and, ultimately, lasting stability. Unfortunately, the immediate need for service delivery during the last decade of war created a system of parallel governance structures as well as a parallel civil service within GIRoA. International military forces and donors often provided essential services directly to local populations working through systems outside of, and not coordinated with, GIRoA institutions. In addition, the international community created a system to fund a “second civil service” of international and national advisors within GIRoA to do the work that civil servants would normally do, with very little transfer of knowledge. As a result, capacity within GIRoA remains extremely limited at all levels.

Furthermore, the government is structured so that most authorities are designated to the central level, which does not allow for local planning and budgeting. The lack of government capacity, combined with the centralized structure, has created a substantial disparity between local needs and the government’s response.

The macro-level issues and challenges described above point to the need for the MoPH to strengthen its ability to think strategically about the future, and to make the difficult decisions necessary to move the health system and quality healthcare for Afghans forward to a more sustainable future. In order to do so, there are key systems and sector constraints that must be identified and reformed to foster health system strengthening and resilience in a way that results in sustained, accessible health care for Afghans and maintains their confidence in GIRoA.

C.2.2. Health System Status

Since 2003, Afghanistan has witnessed significant progress in the health sector under the leadership of the

Ministry of Public Health and with the technical and financial support from USAID and other development partners. GIRoA’s introduction of the Basic Package of Health Services (BPHS) in 2003 and the Essential

Package of Hospital Services (EPHS) in 2005 is widely credited as being the major engine behind these successes. This approach has been critical in ensuring that all donors in the health sector focus on a common strategy for the delivery and expansion of health services throughout the country.

In 2003, the MoPH decided to adopt a stewardship role rather than directly implementing health care services.

That decision resulted in the MoPH contracting out the BPHS and EPHS through non-governmental organizations (NGOs) who are currently funded by donors, which ensure a standardized package of basic services, is available in all health care facilities. Access to basic public health services (ability to reach a facility within one hour by foot) rose from 9 percent in 2001 to 57 percent today.

Leadership/Governance/Accountability (Stewardship)

Strengthening stewardship and good governance are key elements of the National Priority Programs (NPP) of the Afghan National Development Strategy (ANDS). As a steward of the Afghan health system, the MoPH has formulated policy direction, ensured accountability, and carefully monitored and provided oversight of the BPHS and EPHS. However, the MoPH does not have a common definition of stewardship and that concept is not always uniformly applied throughout the various departments within the ministry. The MoPH’s

Strategic Plan 2011-2015, emphasizes the need to improve efficiency, transparency and accountability across the health system through decentralization, transparency in procurement, administrative reform, citizen feedback and anticorruption, and coordination and collaboration within and between Ministries, donors, partners, civil society, communities, and the private sector.

Subnational Governance

The relationship between the central and subnational levels of government in Afghanistan remains somewhat ill-defined. According to Afghan law, Provincial Health Offices (PHOs) are branch offices of the central

MoPH, however, a great amount of work is needed to clarify the roles of the central MoPH’s and the PHO’s and the degree of autonomy at the provincial level. PHOs feel that they cannot be effective at the provincial level, without control of budgets, spending authority, ability to set provincial level policies and increased supervisory responsibility over FPHS contracts. PHOs do not possess the authorities necessary to play a strong stewardship role; their capacity is weak in planning, management, budgeting, leadership and governance; they are weak in key technical areas needed to appropriately monitor BPHS and EPHS activities;

and there is a lack of clarity regarding to whom they are accountable. The Provincial Liaison Directorate

(PLD) itself (the central MoPH directorate responsible for working with provinces) has weak capacity and lacks the strength to monitor and hold the subnational levels accountable. Decentralization – including of hospital financial and procurement functions – is still in its nascent stages, stymied by a lack of will, mistrust, confusion about roles and responsibilities, and a lack of capacity in planning, leadership, management, monitoring, reporting, etc. The central MoPH believes the PHOs lack the capacity to undertake these expanded roles. Given the overwhelming need to increase access to high quality services at the community level, strengthening management capacity at the provincial level, and even lower levels such as the District

Health Office (DHO) and community health shura level, is critical.

Healthcare Financing

The MoPH faces a number of critical challenges in ensuring sustainable financing of the country’s health care system, including inadequate capacity at central and provincial levels in health financing, high out-of-pocket expenditures for health services by the public, low levels of public per capita health expenditure, limited data and analysis of public and private sector health care providers, dependence on donor assistance for the

1 National Risk and Vulnerability Assessment (NRVA), 2007/8 – Bibliography is included as an Attachment

J.11 delivery of health services, and no mature mechanism of revenue generation for the public health sector. The increased engagement of the private sector in the delivery of health services can help mitigate the burdens and challenges facing the public health system noted above.

Under the current fiscal circumstances, the public health system is not self-sustaining; GIRoA revenues are not sufficient to cover the constitutionally-mandated free basic health services. The MoPH estimates that

GIRoA will have an annual health budget shortfall of over $207 million between 2013 and 2020.

In 2011 and 2012, donors contributed roughly 78.6 percent of the MoPH health sector budget.

Major donors intend to continue to support the health sector in the short to medium term; however, this support will become increasingly tenuous as donor funding levels decline. In response, GIRoA has set a goal to reduce MoPH reliance on donor funding from 75 percent to 50 percent by 2017.

To identify other strategies to address revenue shortfalls, the MoPH developed the National Strategy on

Healthcare Financing and Sustainability 2009-2013. This strategy explores demand- and supply-side financing as well as approaches to improve the MoPH’s financial sustainability, including revenue collection and risk pooling mechanisms. Recently, the MoPH has advocated strongly for revenue generation through a series of taxes and user fees. Four taxes are under consideration (tobacco, vehicle, fuel and airline taxes), the revenues of which the MoPH argues should go to the health sector as the externalities of these goods negatively impact public health. User fees at secondary and tertiary level healthcare facilities are currently in negotiation with the Ministry of Justice (MOJ).

Fiduciary Systems

Within the MoPH, responsibilities for budgeting are fragmented, with separate units responsible for the

GIRoA core budget and external on-budget funding. Even among those at the health service implementation level, budget planning and execution capacity (i.e., financial management) is unevenly distributed, with high capacity in many of the BPHS implementing NGOs (which have a high degree of autonomy) and negligible capacity in hospitals. In addition, there is no designated operational budget for MoPH departments, provincial hospitals and PHOs.

Procurement within the core MoPH is another area identified as requiring further strengthening. This area has been relatively neglected in past capacity building efforts because the donor-supported Grants and

Contracts Management Unit (GCMU) has taken the lead role in procurement where external funds are used for delivery of health services.

PHOs currently have relatively minor budgets and also modest capacity, although they are expected to receive a much larger budget allocation once the Provincial Budgeting Initiative (PBI) is implemented under the new

World Bank-managed multi-donor trust fund.

Human Resources for Health

In Afghanistan the human resource crisis is characterized by poor working conditions, including minimal financial compensation, inadequate staffing, lack of career development opportunities or other incentives and worsening security and further exacerbated by chronic inadequacies in both public infrastructure and lack of training capacities, resulting in severe deficits in human resources. Despite the enormous investments to revamp the health infrastructure, capacity and service availability, disturbing trends in workforce migration threaten the gains achieved. According to estimates produced by the Global Health Alliance, the Afghanistan health workforce of 1.08 workers per 1000 population is far less than the 2.5 postulated as needed to achieve the Millennium Development Goals (MDGs).

Another major impediment to improving quality and coverage of service delivery is a lack of female providers, who are in high demand, particularly for child and

2 MoPH, National Health Accounts (NHA), 2011-12.

3 MoPH, Health Economics and Financing Strategy 2013-2020.

4 Chen L, Evans T, Anand S, et al. Human resources for health: overcoming the crisis. Lancet 2004;364:1984-90.

reproductive healthcare.

Estimates from the MoPH indicate a severe shortfall in investments for pre-service training, and this may be further compounded by other phenomena substantiated in some developing countries of internal and external migration and internal misdistribution with a higher density of providers in the urban sector. The demands for health professionals are currently met by 8 medical schools, 8 nursing schools, 8 midwifery schools, 28 community midwifery schools and 6 community nursing education schools that offer pre-service training.

The National Health Workforce Plan (2012–2016) proposes to deploy additionally 7000 nurses, 6000 midwives and 20 000 community health workers to address the current deficits and augment the requirements for achieving the 90% coverage goal for the BPHS.

The failure to generate and maintain a suitably qualified and motivated workforce inevitably leads to reduced productivity or performance at the system level, which will in turn impact overall health system goals including the provision of responsive services and the attainment of health improvements in the population.

Improving the productivity and performance of health workers requires a strategic and multi-faceted approach that is able to provide suitable working conditions as well as appropriate specification and remuneration of tasks to be carried out.

Private Sector

The private sector provides more than 58 percent of the health services in rural areas.

However, while the private sector is a critical component in the provision of health services, it also faces a number of challenges.

Anecdotal evidence suggests that much of the private sector has focused its resources on quantity, often at the expense of quality.

There are a number of private health sector associations, such as the Afghanistan Private Hospitals

Association (APHA) and the Afghanistan National Medical Services Organization (ANMSO) operating in

Afghanistan. While these associations are in the nascent stages of development, they can provide platforms to increase the availability and quality of services in the private health sector.

According to these private health associations, there are approximately 220 private hospitals, 100 private drug producers and importers, and 20 private educational institutes actively involved in health service provision and production in Afghanistan. As defined by GIRoA, the private sector consists of for-profit entities and does not include civil society organizations (CSOs) and NGOs which deliver BPHS and EPHS services. The public and private health sectors are complementary in Afghanistan, especially in the rural areas where most of the maternal and child health care services are provided through the BPHS, while the private sector provides a significant amount of curative care for adults.

The MoPH has made great strides in developing policies and structures regarding the private health sector, such as establishing the Directorate of Private Sector Coordination (DPSC), and implementing the National

Policy for Private Sector. Through this policy, MoPH seeks to increase the impact that private spending has on the health of the Afghan population by positively influencing the types and quality of services and products provided by private health organizations. Implementation of this policy has been weak to date, however, as the MoPH has not been able to effectively conduct oversight or regulatory functions.

The MoPH has also been exploring the use of public-private partnerships with the private sector to provide affordable health care services. This has been a promising area and is one that the MoPH would like to continue to explore, as appropriate.

C.2.3 USAID Development Objectives

Operating under USAID/Afghanistan’s Development Objective 2 (DO 2): Social Gains Enhanced and

Sustained, the goal of USAID’s health program is to improve health outcomes (Intermediate Result 2.1). The

5 Building on Early Gains: Challenges and Options for Afghanistan’s Health Sector, World Bank/USAID/European Union (EU), 2009 project will achieve this goal through provision of high quality health services, coupled with support to strengthening Afghan health systems. The Health Sector Resiliency Project will contribute primarily to

USAID/Afghanistan’s Sub-Intermediate Result (IR) 2.1.1, Afghan Ownership to Ensure an Effective

Response Strengthened, under USAID’s Results Framework by assessing, reforming and strengthening the governance and financing capabilities of the health sector (sub-IR 2.1.1.1), and ensuring that the policy and regulatory environment is conducive to achieving health-related goals (sub-IR 2.1.1.2).

USAID/Afghanistan’s Development Objective 2

C.2.4 Alignment with GIRoA Priorities, Other Development Partners’ Programs and Other

USG Efforts

USAID/Afghanistan’s health sector interventions alone cannot bring about a strengthened national health system or improve the health status of the Afghan population. All USAID efforts must be led by GIRoA, and closely coordinated with donor partners, other USG-funded activities, and other stakeholders. The Contractor will demonstrate how the Health Sector Resiliency Project will actively engage the MoPH, private sector, other donors, development partners, other USAID projects and other stakeholders to communicate, coordinate, and leverage interventions.

Coordination across different USAID programs and partnership at the national and sub-national level is a requirement of this project.

GIRoA Priorities

GIRoA policies and strategies provide the roadmap for USAID’s commitments, as articulated in USG strategies for Afghanistan—to build Afghan ownership and capacity, to strengthen GIRoA accountability and legitimacy, and to improve the health of the Afghan population, especially that of women and girls. Health and education are often the most visible form of government services, especially in rural and remote communities. Effective delivery of these services is critical for building and solidifying Afghan citizens’ trust in government. Sustaining fragile gains in access and quality and eliminating rural/urban and other disparities in health care provision will be an important signal to the Afghan public that GIRoA is capable of governing throughout the country and is deserving of its support.

The GIRoA National Priority Program 5 (NPP-5): Health for All Afghans, the MoPH Strategic Plan 2011–

2015, and that National Health and Nutrition Plan 2012-2020 offer a holistic approach to improving the overall health of Afghans by increasing the provision of quality healthcare services, improving governance and human resources for health, and improving health financing systems. The core premise of NPP-5 is that increasing GIRoA’s accountability, transparency and stewardship capacity in the health sector will lead to improved coverage and quality of primary, secondary, and tertiary health services, thereby increasing the legitimacy of GIRoA and contributing to a healthier population and more productive workforce. The goal of

NPP-5 is to reduce mortality and morbidity by expanding coverage of the BPHS and EPHS.

Linkages with Other Development Partners Supporting Health Systems Strengthening in Afghanistan

USAID/Afghanistan has strategically coordinated with other donors and development partners working in the health sector to distribute the responsibility for certain components of health systems strengthening and health service delivery activities among various stakeholders. Some of the programs being implemented by other development partners that the HSR Project will be expected to coordinate with include, but are not limited to:

∙ World Bank—Results-based financing (RBF) and Capacity Building for Results (CBR);

∙ World Health Organization (WHO) —leadership/governance (policies, strategies, planning, coordination, resource mobilization) and financing (capacity building in resource tracking, costing models);

∙ European Union—health insurance, and leadership and governance, including subnational governance

(aid coordination, decentralization, and capacity development of PHOs, including in planning for the

PBI), pre-service training;

∙ Canadian International Development Agency (CIDA)—financing, including economic evaluations, in-service (IST) training ∙ Australian Agency for International Development (AusAid)—public financial management;

∙ UNICEF—resource mobilization innovations (using mHealth);

∙ Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)—health systems strengthening; and, ∙ Global Alliance for Vaccines and Immunization (GAVI)—MoPH stewardship capacity.

Linkages with Other USAID-Supported Projects in Afghanistan

USAID supports a number of projects both in the health and in other sectors, such as Democracy and

Governance, which potentially overlap with key project areas and with which the HSR Project will be expected to coordinate closely. It will be important to build on the comparative advantage of various partners and programs to increase the effectiveness of this project. The Contractor will demonstrate how the HSR

Project will establish partnerships at all levels to leverage resources, ideas, capacities and technologies to address challenges in health systems strengthening. Some of the key projects with which the HSR Project is expected to collaborate include:

System Enhancement for Health Actions in Transition (SEHAT)

To support GIRoA in providing high-quality health care to the Afghan population, USAID will support access to health services through the Afghan Rehabilitation Trust Fund’s (ARTF) SEHAT Project. SEHAT is an MoPH-led, World Bank-managed program to provide BPHS/EPHS services across all 34 provinces, as well as providing support to strengthen health systems.

SEHAT will also implement a number of HSS programs under “thematic areas” prioritized by the MoPH in collaboration with the donors. Many of these thematic areas will support the work being undertaken by the

HSR Project, including governance and social accountability, fiduciary systems and health care financing, human resources for health, subnational governance, private sector collaboration, and hospital performance.

The HSR Project will not duplicate SEHAT’s on-budget program, but rather will complement these efforts by providing targeted off-budget support the MoPH to implement the SEHAT program and to strengthen and transform the health system.

Family Planning/Maternal, Newborn and Child Health Project (FP/MNCH)

The USAID FP/MNCH Project will support the introduction, scale-up and sustainability of high-impact

FP/MNCH interventions in Afghanistan. Technical assistance provided through the project will increase utilization of high quality FP/MNCH services through culturally-appropriate and cost-effective interventions that will strengthen and enhance existing primary care services provided through both the BPHS and the private sector. The FP/MNCH Project will strengthen referral systems to the EPHS to improve the continuum of care, especially for vulnerable populations. Technical support will also be provided to partners to implement innovative FP/MNCH programs at the community level, evaluate those new interventions and institutionalize successful evidence-based programs into the health system. The FP/MNCH Project, in collaboration with other donors, will also support pre-service training programs.

Initiative to Strengthen Local Administrations (ISLA)

This project, managed out of USAID’s Democracy and Governance Office, strengthens the subnational government systems (planning, operations, communication, representation and citizen engagement) in

Afghanistan to enable GIRoA to improve provincial governance in the areas of fiscal and development planning, representation of citizens, and enhanced delivery of public services. These efforts will help GIRoA prioritize service delivery and develop central plans and budgets that represent provincial interests, and will lead to services that more closely respond to all citizens’ needs in health, education, security, justice and urban services. The project fosters a combination of top-down and bottom-up consultative processes between central and provincial levels to formulate plans and budgets that align with local community service delivery priorities and with national development priorities and available resources. This new project will have a number of possible intersects with the HSR Project’s governance and finance components.

Strong Hubs for Afghan Hope and Resilience (SHAHAR)

The objective of this project, managed out of USAID’s Democracy and Governance Office, is to create well-governed, fiscally sustainable Afghan municipalities capable of meeting the needs of a growing urban population. Targeted support to municipal governments, as well as the General Directorate of Municipal

Affairs (GDMA) and Municipal Advisory Boards (MABs), will lead to improved municipal financial management, urban service delivery, and citizen consultation.

C.3 PROGRAM OVERVIEW

C.3.1 Program Goal and Objectives

The goal of the Health Sector Resiliency Project is to support GIRoA to foster a strengthened, reformed, and increasingly self-reliant Afghan health system prepared for the decreased donor support anticipated over the coming decade. The HSR Project will act as a resource and a catalyst to the MoPH and other GIRoA entities as it considers and implements critical sector-wide reforms that will be required to make the system more resilient and sustainable and reliant on domestic resources. As government reform must be an internally-led process, the MoPH will take the lead in all project activities, while the Contractor serves as a key technical advisor and resource to the MoPH to address the need for increased efficiencies, sustainability, and continued gains in health for all Afghans. It is anticipated that as the sector matures and the donor landscape shifts, the needs and circumstances of the MoPH will change; the HSR Project must be responsive, innovative and flexible to adapt to this fluctuating environment.

The HSR Project will primarily focus on governance, finance and human resources and will engage both the public and private components of the health sector. The project will strengthen the capacity of the MoPH to evaluate and reform the health sector as a discrete unit, developing and implementing solutions that may be difficult politically, but are necessary organizationally and for sustainability. The HSR Project will stimulate and provide assistance to the MoPH to conceptualize and operationalize the more difficult, longer-term decisions/policies that must be made in order to strengthen the system and make continued advances in the health of Afghans, relying increasingly on domestic resources. These could include decisions surrounding how to improve efficiencies and increase the potential for sustainability such as staff rationalization, financial compensation and hiring modalities; organizational restructuring; the contents and cost of the BPHS and

EPHS; strengthening engagement with the private sector; health facility rationalization; and streamlining the

MoPH’s stewardship role. These are some of the important issues that the MoPH will need to address in the near-term if it expects to sustain previous gains, accelerate additional health gains, and secure the capacity and financing necessary to move the MoPH and Afghanistan’s health services beyond the phase of donor dependence. The HSR Project will act as a fulcrum and a resource for the MoPH during the transition, helping to guide the ministry through this ambitious period.

The program goal and objectives are envisioned as follows:

C.3.2 Geographic Scope and Project Coverage

The primary focus of the health sector reform efforts implemented under this project will be at the central level; those efforts are expected to have a nationwide benefit. Select provinces will be identified, in collaboration with the MoPH, USAID and other relevant stakeholders, to implement innovative new subnational health systems strengthening and reform activities.

The Contractor will identify an effective and efficient way to assess and prioritize the needs at the subnational level, understanding that each province will be in a unique situation with distinct capacities and varying levels of previous and on-going support. Through this project, USAID is seeking to identify and pilot innovative, cost-effective approaches to strengthen the health systems at the subnational level.

C.3.3 Guiding Principles

The contractor will follow the guiding principles below as part of its technical approach and project implementation:

Country-led policies and processes: Partnership with the MoPH, private sector and other stakeholders to promote coordinated actions and advance country priorities. Given that GIRoA must be the engine behind any successful health sector reform or strengthening activities, is anticipated that many of the priorities and activities undertaken by the HSR Project will be identified by and implemented at the behest of, and in partnership with, the MoPH.

Sustainable approaches: To ensure that improvements in health system performance achieved through this

Contract will be sustainable beyond the project period by GIRoA, private sector and local organizations. The contractor will provide the technical assistance to strengthen the capacity of local partners and stakeholders to plan, finance, manage, and deliver health care to meet the needs of Afghans over the long-term.

The contractor will support practical, cost-effective approaches to strengthen Afghanistan’s health system.

The Contractor will identify approaches that Afghanistan can afford (either through the domestic public or the private sector) and that can demonstrate results given the country’s challenging circumstances, including declining resources, limited capacity, and uncertain security. The contractor will monitor, document and share information regarding how much each of its actions costs and what results they each produce.

Gender equity and female empowerment: There are numerous gender-related barriers that perpetuate poor health practices and constrain health seeking behavior by women in Afghanistan, many of which are inextricably linked to and defined by Afghan culture. The contractor will support the core development objective of promoting gender equality including support for positive change in attitudes, behaviors, roles, and responsibilities, and female empowerment as members of families, in communities, as members of the workforce and in health policy and leadership. The HSR Project must demonstrate gender mainstreaming in its staffing, partnerships, program planning, implementation and evaluation.

Program learning: Support scaling-up of evidence-based best practices in health sector reform and health systems strengthening based on a program learning agenda and application. The Contractor will design a robust learning agenda in order to better understand the public and private health sector in Afghanistan and use best practices to recommend innovative ways in which they would benefit from reform and systems strengthening activities. It will be important for the HSR Project to adapt and apply relevant best practices from other countries in the region and globally to health sector reform and systems strengthening in

Afghanistan. The contractor will collect and disseminate data on the private sector to strengthen linkages between the public and private health sectors and to identify opportunities to better leverage resources from the private sector.

The contractor will support the MoPH to scale-up evidence-based best practices in health sector reform and health systems strengthening based on a robust program learning agenda and field application. The project will facilitate the evaluation, documentation and dissemination of implementation successes and failures towards continuous quality improvement of health systems. Contracts issued by the Mission are expected to comply with the Agency Policy on reporting, cataloging, and publishing data produced by its project.

Science, technology, innovation: The contractor will foster innovative approaches to strengthen the health system. Innovations do not need to be high tech, the focus instead should be ensuring they are low cost, suitable for Afghanistan, and incorporated only if/when appropriate for a particular intervention. USAID will only support the development of a new tool, system or methodology when USAID and GIRoA partners agree that developing a new system is a good value for USAID’s money and meets a defined need of Afghanistan and that such a system is not available in the public domain.