SOL-306-15-000049_IHSAN_RFP_Amend_01.pdf

Issuance Date: April 30, 2015 Deadline for Questions: May 8, 2015 at 17:00, Washington DC Time (01h30 Kabul time) Closing Date: June 25, 2015 Closing Time: 17:00, Kabul Time (08h30 Washington time)

Subject: Request for Proposal No. SOL-306-15-000049 – Initiative for Hygiene, Sanitation, and Nutrition

(IHSAN)

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 the Initiative for Hygiene, Sanitation and Nutrition (IHSAN) project to support the Government of the Islamic Republic of Afghanistan (GIRoA) to improve the nutritional status of women of reproductive age and children less than five years old, 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 of the contract (cost and fee) is between $70 and $80 Million. USAID’s principal geographic code defining eligible sources and nationalities for this procurement is 937. The NAICS code is 541990.

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 the contract with blanks to be completed by the Contracting Officer upon award.

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 must 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 the RFP cover letter. 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 Maria Elena Burgos at meburgos@state.gov and Stephen Wiese at swiese@state.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 in writing at the Federal Business Opportunities (FedBizOpps) website. Please check this website periodically to ensure that you have received the most up-to-date information regarding this solicitation.

If substantive questions are received, which affect the responses to the solicitation, or if changes are made to the closing date and time, as well as any other aspects of the RFP, this solicitation will be amended. Any amendments to this solicitation will be issued and posted on the Federal Business Opportunities (FedBizOpps) website. Offerors are encouraged to check this website (http://www.fbo.gov) periodically.

mailto:meburgos@state.gov mailto:swiese@state.gov

PART I – THE SCHEDULE

SECTION B - SUPPLIES OR SERVICES AND PRICES/COSTS

B.1 PURPOSE

The objective of the Initiative for Hygiene, Sanitation, and Nutrition (IHSAN) project is to improve the nutritional status of women of reproductive health and children less than five years old, with a focus on the first 1,000 days (conception to 24 months of age). The expected outcomes of the IHSAN are to decrease stunting by at least 5 percent (i.e. 2 percent reduction from the current rate) over five years, and reduce anemia among women of reproductive age by at least 10 percent.

B.2 CONTRACT TYPE

This is a Cost-Plus-Fixed-Fee (CPFF) Completion type contract. For the consideration set forth below, the Contractor will provide the performance requirements described in Section C and the deliverables described in Section C and F.

B.3 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. 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.6 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.4 INDIRECT COSTS

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

Description Rate Base Type Period

1/ 1/ 1/ 2/ 2/ 2/ 3/ 3/ 3/

1/Base of Application:

Type of Rate: Predetermined Period:

2/Base of Application:

Type of Rate: Predetermined Period:

3/Base of Application:

Type of Rate: Predetermined Period:

For Each of the Major Subcontractor(s)*

Description Rate Base Type Period

1/ 1/ 1/ 2/ 2/ 2/ 3/ 3/ 3/

1/Base of Application:

Type of Rate: Predetermined Period:

2/Base of Application:

Type of Rate: Predetermined Period:

3/Base of Application:

Type of Rate: Predetermined Period:

*”Major Subcontractors” are those subcontractors whose proposed cost exceeds 15% of the total estimated Contract cost.

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 MULTI-YEAR CONTRACT AND CANCELLATION CEILING

This contract is considered non-severable, and is therefore a multi-year contract as defined in FAR 17.103.

Therefore, this contract is subject to the requirements of FAR 17.106.

a. Performance under this contract during the second and subsequent program years is contingent upon the appropriation of funds. All program years except the first are subject to cancellation. Cancellation shall occur by the dates specified below if the Contracting Officer:

1. notifies the Contractor that funds are not available for contract performance for any subsequent program year, or

2. fails to notify the Contractor that funds are available for performance of the succeeding program year.

b. 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.

The Government's liability for cancellation charges shall not exceed $0. This amount will be reduced in accordance with FAR 17.106-1(c)(1) at the conclusion of each program year, as follows:

Program Year Cancellation Date Cancellation Ceiling

Year 1: 2015/2016 N/A N/A Year 2: 2016/2017 March 31, 2016 $0 Year 3: 2017/2018 March 31, 2017 $0 Year 4: 2018/2019 March 31, 2018 $0 Year 5: 2019/2020 March 31, 2019 $0

[END OF SECTION B]

SECTION C – DESCRIPTION/SPECIFICATIONS./STATEMENT OF WORK

Acronym List:

AFSANA Afghanistan Food Security and Nutrition Agenda BPHS Basic Package of Health Services CDC Community Development Council CHW Community Health Worker CLTS Community-led Total Sanitation CO Contracting Officer COR Contracting Officer’s Representative CSO Civil Society Organization DFATD Canada-Department of Foreign Affairs, Trade, and Development ENA Essential Nutrition Actions EHA Essential Hygiene Actions EU European Union FP/MNCH Family Planning/Maternal-Newborn-Child Health GAIN Global Alliance for Improved Nutrition GIRoA Government of the Islamic Republic of Afghanistan HANCI Hunger and Nutrition Commitment Index HED MAIL’s Home Economics Department IHSAN Initiative for Hygiene, Sanitation, and Nutrition ICT Information Communication and Technology IEC Information Education and Communication IMAM Integrated Management of Acute Malnutrition IYCF Infant and Young Child Feeding MAIL Ministry of Agriculture, Irrigation, and Livestock MRRD Ministry of Rural Rehabilitation and Development MoE Ministry of Education NAF Nutrition Actions Framework NCI Nutrition Commitment Index NGO Non-governmental organization NNS National Nutrition Survey (2013) ODF Open-defecation free PHCC Provincial Health Coordination Committee PPHD Provincial Public Heath Directorate PND Public Nutrition Department PMP Performance management plan PRRD Provincial Rural Rehabilitation and Development RUTF Ready-to-Use Therapeutic Food RUSF Ready-to-Use Supplementary Food SAM Severe Acute Malnutrition SEHAT System Enhancement for Health Actions in Transition TAG Technical Advisory Group ToT Trainers of Trainers UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government WASH Water, Hygiene, and Sanitation WB World Bank WHO World Health Organization

C.1 Introduction

The Initiative for Hygiene, Sanitation, and Nutrition (IHSAN), a five-year project, is a multi-sectoral, integrated project that focuses on a three-prong approach: (1) improving the delivery of nutrition, hygiene, and sanitation specific and sensitive services within the existing systems1 of Afghanistan, with a particular focus on the public health system’s basic package of health services (BPHS)2; (2) fostering rapid adoption of optimal nutrition, hygiene, and sanitation behaviors at the household and community levels; and (3) increasing availability of nutrition and sanitation products and services. IHSAN is implemented through a system strengthening approach, utilizing the BPHS and other existing Afghan systems across sectors. IHSAN will closely align with the USAID Multi-Sectoral Nutrition Strategy3 and the USAID Water Strategy.4

C.2 Background

C.2.1 Problem Statement

Despite progress made to date, Afghanistan continues to face high levels of malnutrition that contribute to limiting the country’s socioeconomic development.

Under-nutrition is a significant issue in Afghanistan:

Despite progress during the last ten years, under-nutrition and impaired physical development remain very high.

Nationally, 41 percent of children less than five years old are stunted, 10 percent are wasted, and a quarter is under-weight. The level of severe malnutrition is very high (9.5 percent of children less than five years old are estimated to be severely malnourished), with an estimated 2.6 million children in need of treatment per year.5 Though there is a wide variation of these rates among provinces, the overall nutrition situation of children less than five years old is critical and is one of the GIRoA’ s priorities.

Micronutrient deficiencies are also widespread in Afghanistan. Anemia is common among women of reproductive age (40 percent) and among children under five years old (45 percent). Vitamin A deficiency among children less than five years old is a severe public health problem for the country; and zinc deficiency was reported in both women (24 percent) and children (15 percent).6

Key determinants of this situation in Afghanistan are:7

• Food insecurity: 28 percent of households have inadequate calorie intake and more than 30 percent of households consume diets with inadequate food diversity;

• Limited capacity of health staff to provide quality nutrition services limits the integration of essential nutrition actions8 with maternal and child health services;

• Inadequate care for women and children: women have very limited influence on how resources are spent, which foods are purchased and consumed for themselves and their young children; limited time and awareness to care optimally for the infant/young child; and limited access to a supportive environment to address their own stressors.

Poor hygiene and sanitation environment:

1 This activity focuses not only on the BPHS system of service delivery. It also calls for strengthening alternative delivery systems (CSOs) through innovative practices to reach the most vulnerable groups, including the urban poor.

2 Delivery of services entails both quality of services and linkages from community health services delivery to facility and vice versa.

3 USAID Multi-Sectoral Nutrition Strategy 2014-2015 4 USAID Water and Development Strategy 2013-2018 5 This project does not include provision of commodities such as RUTF, RUSF, or other commodities. The scope of this project can include building the capacity to screen and refer for treatment of malnutrition.

6 National Nutrition Survey 2013 7 Levitt E., et al: Malnutrition in Afghanistan: Scale, Scope, Causes, and potential Response. Directions in Development. The International Bank for Reconstruction and Development/the World Bank. 2011 8 Essential nutrition actions are clearly defined in the Maternal Child Nutrition Lancet Series 2013

Extensive evidence supports the hypothesis that a higher cumulative burden of diarrhea increases the risk of under-nutrition.9 The latest research shows that high pathogen environments and poor WASH conditions are also causes of under-nutrition.10 In Afghanistan, hygiene practices remain poor, despite the inclusion of hygiene and sanitation interventions as part of the overall BPHS. Though many households report knowing the importance of washing hands with water and soap to reduce the spread of diseases, hand-washing practices are limited. It is estimated that only half of all households have access to soap at the hand-washing place.11 Across Afghanistan, 40 to 80 percent of people self-report the practice of hand-washing just before eating in various studies.12 Only half the rural population has a designated hand-washing station in their household areas.13 Poor hygiene and sanitation result in increased risks of diarrhea for children. The National Nutrition Survey (NNS) 2013 data shows that 25 percent of children were reported to be suffering from diarrhea in the two weeks preceding the survey; in some provinces the rate was a high as 40 percent.14 The trends in sanitation improvement have been slow. The prevalence of open defecation is declining (from 28 percent of households in 2000 to 15 percent in 2012). More than half (56 percent) of the Afghan population practices fixed-place defecation in composting toilets and uses human excreta as fertilizer.15

Some of the critical WASH actions that the Contractor must bring to scale to improve nutrition outcomes are:

• Increased availability of safe water at the household level;

• Increased adoption of hand-washing practices during critical times, such as during feeding infant and young children and after urinating or defecating;

• Improved food preparation and storage; and

• Increased safe disposal of feces, including safe disposal of child feces.

C.2.2 USAID Development Objectives

USAID/Afghanistan has clearly identified that investments in nutrition, through a multi-sectoral approach, are critical to support economic and social development and to provide increased stability supportive of national security.16 IHSAN will contribute to the USAID/Afghanistan Transformation Strategy by specifically contributing to Development Objective (DO) 2: Gains in Health, Education and the Empowerment of Women Maintained and Enhanced; IR 2.1: Health Outcome Improved; IR2.3: Women’s Equality and Empowerment Increased; and to DO 1:

Sustainable, Agriculture-led Economic Growth Expanded. In 2013, USAID launched a Water and Development Strategy, followed in 2014 by a Multi-Sectoral Nutrition Strategy, both of which frame key priority areas for USAID. Nutrition experts describe how integrating WASH and nutrition is critical to improving nutrition outcomes.

Increasing access to and use of safe water, sanitation facilities, and good hygiene practices have the potential to positively affect nutritional outcomes by addressing both the immediate and underlying causes of malnutrition.17

C.2.3 Alignment with GIRoA Priorities and Other Donor Programs

GIRoA’s Strategies and Priorities:

9 Pruss-Ustun, A et al. Burden of disease from inadequate water, sanitation, and hygiene in low and middle-income settings: a retrospective analysis of data from 145 countries. Trop. Med. Intl. Health, in press 10 Lin A, Arnold BF, Afreen S, Goto R, Huda TM, Haque R, Raqib R, Uicomb L, Ahmed T, Colford JM and Luby SP.

Household Environmental Conditions Are Associated with Enteropathy and Impaired Grown in Rural Bangladesh. Am. J. Trop.

Med. Hyg. 2013; 89 (1): 130-137.

11 NNS 2013

12 ACTED. Knowledge, Attitude, Practice (KAP) Study on Hygiene. ACTED and UNICEF. 2013; and Rehman, Mokhelesur and Abdul Rasheed. A Study of Knowledge, Attitude and Practices of Children Care givers Regarding Polio and Routine Immunization in 13 High Risk Districts, South Region, Afghanistan. Youth, Health and Development Organization. 2012 13 Ibid 14 National Nutrition Survey Afghanistan 2013 15 UNICEF WASH Presentation to USAID November 2015.

16 USAID/Afghanistan Transformation Strategy 2014; USAID/Afghanistan Nutrition Concept Note, 2014; USAID/Afghanistan WASH Concept Note, 2013.

17 Cumming, WASH and Nutrition Pathways, 2013.

Many ministries play a role in improving nutrition, including by increasing access to safe water and promoting the adoption of key hygiene and sanitation behaviors. Several policies, strategies, and guidelines in the nutrition and WASH sectors have been developed, but implementation remains a challenge. There is limited coordination to-date across all stakeholders.

Afghanistan has made recent strides to create the policies necessary to coordinate a multi-sectoral approach to combat under-nutrition. The Afghanistan Food Security and Nutrition Agenda (AFSANA) reaffirms GIRoA’s commitment to address the multiple determinants of hunger and malnutrition in a coordinated fashion through an Executive Committee chaired by the Second Vice-President. The second key GIRoA document is the Nutrition Actions Framework (NAF), 2012-2016, which clearly delineates actions that all ministries can take to integrate nutrition within their mandate.

The MRRD supports the implementation of Afghanistan’s National Rural WASH Policy (2010-2015) to increase access to potable water; achieve “Open-Defecation Free” (ODF) villages; and integrate hygiene education in schools, communities, and households. In some provinces, MRRD has established Community-Led-Total Sanitation (CLTS) teams to build the capacity of Community Development Councils (CDCs) to achieve ODF status for their communities.

The MAIL promotes food security and farmer income by increasing food productivity, which includes increasing production of staple food crops, such as wheat, as well as increasing cash crops to improve family income.

Nevertheless, these initiatives have had limited integration with nutrition sensitive interventions. To correct this, the Home Economics Department (HED) has tried to promote adoption of optimal food preparation and storage practices at the community level.

GIRoA’s ability to harness the private sector to improve nutrition is also limited. Discussions on food fortification and marketing nutrition products, such as enriched complementary foods have started. The Global Alliance for Improved Nutrition (GAIN) is leading these discussions to raise attention on nutrition in agricultural and industrial production activities.

Coordination with other Development Partners’ Programs:

IHSAN will complement other donor-funded nutrition programs, such as the delivery of nutrition-specific services funded by the System Enhancement for Health Actions in Transition (SEHAT) project; the European Union (EU), Canada’s Department of Foreign Affairs and Development (DFATD), and UNICEF programs for short-term capacity building in nutrition, which targets the NGOs contracted to deliver the BPHS; the EU-funded initiative to integrate nutrition pre-service programming in existing Afghan institutions;18 and others.19

C.3 Goal, Objectives, and Results Framework

The period during pregnancy and the first two years of life are the critical windows of opportunity to improve nutrition and decrease stunting during the most vulnerable phases of human life. By age two, stunting, as well as physiological impairments occurred during this critical development period are irreversible. The goal of the project is to improve the nutritional status of women of reproductive age and children less than five years old, with a focus on the first 1,000 days (conception to 24 months of age). The expected impact of IHSAN is to decrease stunting by at least five percent (i.e, a decrease in the national estimated stunting rate of 41% to 39% nationwide)20 and to decrease anemia in women of reproductive age by at least 10% (i.e., a decrease in the rate from 40% to 36%) over the five-year implementation period.21 The Lancet series on nutrition established a solid base of evidence on the

18 See Attachment J.10 “Overview of EU planned interventions in nutrition under the Annual Action Plan 2014” 19 See Attachment J.11 “The Importance of Permaculture-based Kitchen Gardening – The NAEC Approach” for a discussion of a Dutch-funded program that integrates nutrition in existing agriculture technical vocational schools (TVETs).

20 The decrease in stunting by 5% (from 41% to 39%) is the MoPH target per the National Nutrition Strategy. The decrease in anemia is also in line with MoPH targets. The contractor must meet these targets if not exceed them.

21 Results shall be measured by the planned Nutrition Surveys (national and also small surveys, Demographic Health Survey).

Program Implementation indicators measuring changes of practices shall be rigorously collected throughout the activity. See illustrative indicators. The Contractor is strongly encouraged to propose additional indicators.

importance of preventing stunting, focusing on the “development window of opportunity,” referring to the first 1,000 days of life when children are growing rapidly, are most vulnerable to growth faltering, and are most responsive to nutrition interventions.

Evidence shows that decreasing stunting and the associated abnormalities due to impaired physical and physiological development requires a multi-sectoral approach where children less than two years old, mothers, pregnant women, and adolescent girls have access to quality nutrition and health services; where children less than two years old have a clean, safe, and caring environment to thrive; and where access and utilization of diversified foods at the household level is key.

IHSAN has three objectives:

Objective 1: Capacity to institutionalize nutrition programs enhanced Objective 2: Adoption of optimal nutrition and hygiene behaviors at community and household levels increased Objective 3: Availability of nutrition, hygiene, and sanitation services and products increased

See results framework below.

C.3.1 Geographic Focus

IHSAN will focus efforts for technical leadership in nutrition, hygiene, and sanitation both at the national and provincial levels. At the national level, the Contractor must provide technical assistance to the existing GIRoA structures, such as the MoPH’s health delivery systems with a focus on the BPHS22 and MRRD and at the provincial level with Provincial Rural Rehabilitation and Development (PRRD) Offices and CDCs. The Contractor

Goal: Improve nutrition status of women and children less than five years old, with a focus on the first 1,000 days of life

Capacity to institutionalize nutrition

Nutrition environment enhanced

Afghan institutions delivering nutrition and WASH in-service training established

Public Nutrition Department and service providers’ leadership strengthened

Optimal nutrition amd WASH behaviors

Household nutrition and WASH behavior improved

Use of nutrition-specific health services by women and children increased

Private sector in Social Behavior Change Communication utilized

Availability of nutrition and WASH services and products

Access to and consumption of nutritious foods increased

Access to WASH services and products increased

Women empowerment strengthened

Cross-cutting themes: Innovations, Gender, and Learning must also focus nutrition and WASH activities in at least ten provinces, namely Farah, Nuristan, Kunar, Paktia, Ghor, Nangarhar, Badghis, Bamyan, Badakshan and Samangan. The Contractor must start provincial level work from the first year, either as direct implementation and/or through the “Innovation Fund.”2223

C.3.2 Beneficiaries

The Contractor must target its resources to meet the health needs of mothers and children, focusing on the first 1,000 days of a child’s life (conception to 24 months of age) and specifically focusing on pregnant women, lactating mothers, and children less than two years of age.

C.3.3 Implementation Principles

Host-country system strengthening:

To ensure greater sustainability and host-country ownership, the Contractort must work within the existing systems across the three objectives, including:

• The health sector with the MoPH and its framework of BPHS;

• The MRRD strengthening the CLTS strategies;

• Independent Directorate for Local Government, building local governance at provincial and district level;

• The agriculture sector, including MAIL and agricultural extension programs;

• Non-governmental organizations contracted by the MoPH to deliver nutrition specific services and/or NGOs delivering the National Security Program activities;

• Community systems, such as health shuras, women’s shuras, farmers groups, and religious and community leaders;

• The private sector; and

• Existing Afghan training and research institutions.

Working within the existing country systems and particularly strengthening ownership and leadership of key ministries, such as the MoPH, the MRRD, and the MAIL, will ensure that work in nutrition, sanitation, and hygiene continues once the project ends.

Responding to the socio-cultural and economic context of Afghanistan: Afghanistan provides unique challenges due to its geographic and population diversity and its rapid urbanization rate. Changing attitudes and practices that lead to improved nutritional status, improved hygiene and sanitation behaviors, and access to services and products requires a deep understanding of the socio-cultural and economic context of the populations to be served under this project. Tailored strategies and activities to address barriers that hinder optimal nutrition must be based on a deep understanding of that context, specifically to reach lactating/pregnant women and children less than two years old in both rural and urban areas.

Gender, equality, and female empowerment: The Contractor must support USAID’s core development objective of promoting gender equality24 across IHSAN’s three objectives. The Contractor’s success will rely on sensitive outreach and broad engagement of the larger community in support of women’s increased decision-making regarding nutrition.

Science, technology, and innovations: The Contractor must develop a strong partnership with the private sector, bolstering adaptation of scientific and low-cost technological advances that promote hygiene and sanitation and optimal nutrition for pregnant women, infants, and young children. For example, the Contractor must incorporate the

22 Afghanistan Rural Water and Sanitation Sector – Coverage Assessment Report (2012) list 25 provinces with less than 4.1 percent improved sanitation coverage as Badakhshan, Badghis, Baghlan, Balkh, Bamyan, Daykundi, Farah, Ghazni, Ghor, Helmand, Herat, Kabul, Kandahar, Kunar, Kunduz, Lagman, Logar, Nimroz, Paktya, Parwan, Samangan, Takhar and Urzugan.

23 The National Nutrition Survey 2013 identifies key provinces with high levels of malnutrition and poor nutrition/hygiene/sanitation behaviors.

24 USAID Gender Equality and Female Empowerment Policy March 2012 use of mobile technology and other related innovative technology approaches to the extent practicable in the design and implementation of all activities across the three objectives.

Program learning: The Contractor must support the scaling-up of evidence-based best practices in nutrition based on a robust learning agenda. The Contracor must review the current evidence and conduct research when needed to rigorously identify gaps in access, utilization, equity, and quality of nutrition and hygiene specific interventions delivered through the health systems and of nutrition sensitive interventions across sectors, such as agriculture, education, and water. To date, there is not much evidence on how best to integrate nutrition, hygiene, and sanitation activities. Through a rigorous learning agenda, the Contractor must support the gathering of evidence on how to best co-locate and implement hygiene and sanitation activities with nutrition activities to decrease stunting.

C.3.4 Scope of Work

Currently, 60 percent of the population (estimated at 30 million) is being reached by the BPHS. The Contractor must increase the quality of and reach, access, and utilization of the full package of nutrition-specific services delivered through the BPHS and community delivery systems to pregnant women, lactating mothers, children less than two years of age, and children less than five years old.25 In addition, the Contractor must implement nutrition-sensitive interventions to improve the nutritional status of these beneficiary groups.26 See section C.9 for minimally acceptable targets that the Contractor must reach yearly and through the life of the project.

Objective 1: Capacity to institutionalize nutrition programs enhanced27 (LOE: 25 percent)

To accomplish Objective 1, the Contractor must implement activities, identified through annual work plans, to achieve the following outcomes:28

• Overall nutrition enabling environment strengthened by operationalizing existing multi-sectoral policies and frameworks, specifically the AFSANA, NAF, and WASH Policy, as well as turning the Nutrition and Water Sector Coordination bodies into effectively functioning bodies29 with a particular focus at the national level, on Inter-Agency Standing Committees,30 the Nutrition Coordination Group led by the Public Nutrition Department (PND),31 and the Water Sector Group led by MRRD;32

• Provincial Health Coordination Committees, Provincial Water Sector Committees, and District Rural Rehabilitation Departments33 effectively integrating nutrition programming realized;

• MoPH’s PND nutrition technical leadership and organizational capacity at national and provincial level increased;

• Non-governmental organizations’34 including BPHS implementers’ and civil society organizations35’ (women’s organizations, farmers organizations, health shuras, CDCs, CLTS teams’) capacity to provide nutrition, hygiene, and sanitation services increased;

25 The core nutrition package for pregnant women include iron/folate supplementation, deworming, micronutrient supplementation, salt iodization, and counseling on maternal nutrition and exclusive breastfeeding. The core package for infant and young children for nutrition services include: promotion of exclusive breastfeeding and promotion of complementary food;

VA supplementation, micronutrients and iron supplementation; growth monitoring and counseling; community-based management of malnutrition; and treatment of diarrhea with ORS and Zinc.

26 Nutrition-sensitive activities include but are not limited to hygiene and sanitation promotion and increasing food diversity.

27 In line with the objective of integrating WASH with nutrition activities, nutrition programs are defined as programs to improve maternal and child nutrition with an integration of improving hygiene and sanitation, 28 As a baseline, the Contractor can use the results for the Assessment of the Nutrition Interventions in the BPHS and EPHS, the WB review of the Nutrition Sector: Malnutrition in Afghanistan, Scale, Scope, Causes, and Potential Response.

29 AFSANA and Nutrition Actions Framework define Coordination Mechanisms.

30 Inter-Agency Clusters in Health, Nutrition, WASH, Food Security led by GIRoA and UN Agencies.

31 PND is leading a Nutrition Coordination Committee that includes Development Partners and representatives of civil society.

32 The proposal must reflect the priorities of the Minister of Health regarding Coordination groups.

33 The contractor must support the technical training and capacity building for sector-wide planning of Tashkeel staff at the MRRD (national), PRRDs (provincial), and District Rural Rehabilitation Departments in key priority provinces.

34 NGOs include a wider group than the BPHS NGOs but do include the BPHS NGOs.

• In-service training36 program (in line with global standards) institutionalized in public and private Afghan institutions across sectors and complementing other development partners’ funded pre-service programs in hygiene, sanitation, and nutrition.3738

1.1 Nutrition environment enhanced:

The Contractor must provide technical assistance services to the Ministry of Public Health (MoPH); other Government of the Islamic Republic of Afghanistan (GIRoA) entities, such as the Ministry of Agriculture, Irrigation, and Livestock (MAIL) and the Ministry of Rural Rehabilitation and Development (MRRD) as well as to non-governmental organizations39 and the private sector to implement evidence-based essential nutrition, hygiene, and sanitation actions. The Contractor must also integrate into its efforts Afghan-led game-changing interventions that can significantly reduce stunting and improve nutrition outcomes for women and children. As IHSAN is a multi-sectoral project working across ministries, a multi-disciplinary Technical Advisory Group (TAG) with representatives from the Contractor, USAID, and GIRoA will advise the implementation of project activities. The TAG will not, under any circumstance, direct the Contractor or direct implementation of project activities.

At the national level, the Contractor must provide technical assistance to GIRoA to strengthen the nutrition environment. The Contractor must provide services to GIRoA to implement the Afghanistan Food Security and Nutrition Agenda (AFSANA) and the Nutrition Action Framework (NAF). Both documents have been endorsed by GIRoA, but their implementation is limited. Specifically, the Contractor must support GIRoA’s efforts to establish the High Executive Steering Nutrition Committee, chaired by the Second Vice-President, to coordinate activities across ministries to improve nutrition.40 The Contractor must support GIRoA by sharing global evidence-based nutrition and WASH initiatives that have demonstrated results to reduce stunting and address anemia. Evidence will include technical updates, lessons learned and, costing of nutrition services for GIRoA including Parliamentarians41 to make informed choices regarding operationalizing multi-sectoral nutrition policies.

The Contractor must build Afghan advocacy for nutrition with a special focus on prioritizing infant and young child feeding (IYCF) by organizing policy dialogues and learning exchanges within Afghanistan and other regional countries. GIRoA’s commitment to nutrition will be measured by the Nutrition Commitment Index (NCI), which is part of the Hunger and Nutrition Commitment Index (HANCI). Afghanistan currently ranks 20th out of 45 countries on the HANCI. The Contractor must support GIRoA’s efforts to develop a separate budget for nutrition; to integrate nutrition features in the National Development Policy; to increase access to improved sanitation and improved drinking water; and to increase healthcare visits for pregnant women that include nutrition-specific services.42 The Contracor must contribute to Afghanistan meeting some of the defined areas for improvement as defined by the

HANCI 2013.

At the provincial level, the Contractor must assist the existing multi-sectoral Coordination Mechanisms, such as the Provincial Public Health Coordination Committee, the Provincial Councils, and Provincial Water Sector Groups, etc. to harmonize and coordinate nutrition, sanitation and hygiene programs. Streamlining these groups, clearly defining terms of reference to avoid redundancy, and building their organizational and technical capacity is one of the GIRoA’s priorities towards greater effective decentralization. The Contractor must provide technical assistance

35 CSOs include women’s organization, farmers’ groups, health shuras, women’s shuras, Community Development Councils. The CDCs and DRRDs are critical to be included in the program as in the future these shall be responsible for implementing the National Rural WASH Action Framework and provincial and district WASH programs.

36 In service training includes a whole range of capacity building activities: core competency training, distance learning, mentoring/coaching, and others.

37 There are several in-service trainings already developed by MoPH.

38 EU will fund a nutrition capacity building project, focusing on pre-service training. Kabul Medical University and Ghazanfar Institute of Health Sciences are the two institutions where the EU funded project shall focus on.

39 Non-governmental organizations include NGOs that deliver the BPHS and NGOS that outside the BPHS. The EU will also be funding a large capacity building project specifically tailored to BPHS NGOs. Both EU and USAID projects are complementary and shall liaise closely.

40 AFSANA

41 UNICEF has already initiated work with Parliamentarians and has formed a coalition of MPs. The Contractor shall liaise closely with the existing group and UNICEF and shall provide technical leadership on demand.

42 www.hanciindex.org for greater use of nutrition and hygiene sanitation data for decision-making across sectors. The Contractor must build capacity of these coordination groups to advocate for greater allocation of resources to improve nutrition and WASH and to effectively engage representatives of line ministries, civil society,43 and the private sector.

1.2 Afghan institutions delivering nutrition and WASH in-service training strengthened:

Starting in the first project year, the Contractor must assist MoPH/PND to: revise existing in-service training packages44 for different cadres of health workers, including community health workers, to ensure these are in line with global standards; test appropriate distance learning systems for PNOs, community midwives, nurses, and doctors; develop coaching and mentoring systems; and implement on-the job training activities with a focus on the primary-care level.45

The EU, DFATD, and UNICEF are funding capacity building programs for BPHS NGOs using a Training of Trainers (ToT) model. Based on a needs assessment, the Contractor must support GIRoA’s efforts to scale up the existing BPHS NGOs’ nutrition refresher training activities in key provinces.

As the BPHS is not reaching an estimated 40% of the Afghan population, the Contractor must prioritize building the capacity of the BPHS NGOs to plan and implement outreach nutrition and WASH activities at the community level, beyond facility-based delivery of nutrition/WASH services. The Contractor must support GIRoA’s efforts to build the core nutrition and WASH competencies of CHWs and their supervisors, which to date have had a very limited role in implementing these services.46 The Contractor must test models to incentivize non-GIRoA frontline workers, such as CHWs, to become “nutrition, hygiene, and sanitation” agents of change, either through financial or non-financial means. This incentive program needs to be delivered in tandem with in-service training to enhance CHW commitment.

The Contractormust support adaptation to the Afghan context of new continuous capacity building models, such as distance learning, internships, job experience opportunities, coaching and mentoring, possibly using mobile technology amongst other options. The Contractor must organize multi-sectoral learning opportunities and/or provincial and district level exchanges on promising capacity-building activities to improve core competencies in nutrition, hygiene, and sanitation.

The Contractor must also assist other line ministries (MAIL, MRRD, and the Ministry of Higher Education (MoHE)) to build the capacity of community-based workers (agricultural extension workers, CLTs, teachers, CDCs) by integrating nutrition, hygiene, and sanitation modules into existing in-service trainings activities.

Given the limited nutrition curricula in institutions and lack of nutritionists within the GIRoA sectors, the Contractor must assist GIRoA to develop effective in-service nutrition trainings with existing Afghan institutions. The Contractor must support GIRoA in identifying existing Afghan institutions that can provide nutrition in-service training both at national and provincial levels. IHSAN supported in-service training will complement the European Union-funded nutrition pre-service program.

Critical to a country-led, sustainable approach is building the institutional capacity of existing Afghan institutions in nutrition. The Contractor must partner with universities or key leading training institutes in nutrition to ensure that in-training services and nutrition research capacity are developed in line with global standards and that a long-term partnership with a global institutional leader in nutrition is established. From the second year onward, the Contractor must assist the MoPH, the MRRD, and the MAIL to identify existing public and/or private Afghan institutions to integrate nutrition, hygiene, and sanitation modules into formal in-service training curricula for existing cadres of frontline workers across sectors. The Contractor must assist GIRoA to develop in-service nutrition and WASH curricula tailored to doctors, midwives, and nurses to be used by existing Afghan institutions. The Contractor must assist the MoPH and MoHE to develop official government certification processes for these in-service training

43 Civil society is broader than solely the NGOs contracted to deliver health services 44 Existing packages to date include IYCF, treatment of malnutrition, iron/folate supplementation, nutrition counseling, growth monitoring, and promotion.

45 Community midwives, nurses, CHWs, Community Health Workers Supervisors 46 Consultations with BPHS NGOs and MoPH 2014 curricula so they can be easily incorporated by Afghan institutions at provincial levels. The USAID funded in-service training must complement the pre-service training funded by the European Union.

1.3 Public Nutrition Department and service providers’ leadership strengthened:

The Contractor must assist the MoPH/PND both at national and provincial levels to program, coordinate, and monitor nutrition-specific interventions, including hygiene and sanitation promotion provided through the BPHS.

The Contractor must identify the organizational and technical gaps of MoPH/PND both at national and provincial levels and implement activities to address these gaps. Specifically, the Contractor must assist the MoPH to strengthen the role and core competencies of Provincial Nutrition Officers (PNOs) to effectively monitor the MoPH-contracted NGOs providing the nutrition-specific services in the BPHS.47 Until now, nutrition is not seen as an integral part of the BPHS,48 the Contractor must build the capacity of the Provincial Public Health Directorate and staff to understand the importance of improving nutrition services for women and children. IHSAN will contribute to a revised BPHS structure, where NGOs contracted for the BPHS will have dedicated staff for nutrition programming, where BPHS monitoring checklists will include key nutrition indicators, and where PNOs will have the capacity to monitor the delivery of the nutrition-specific services in the BPHS.49

The Contractor must assist GIRoA, specifically MoPH, to review existing nutrition and WASH protocols and guidelines to ensure these include evidence-based key interventions and are standards-based. In collaboration with GIRoA, the Contractor will conduct a review of the existing policies, protocols, and training packages to identify critical gaps. Based on the review findings, the Contractor will provide technical assistance to develop up-to-date protocols and guidelines.

The Contractor must achieve the following Objective 1 Deliverables:

• Assistance provided to implement the AFSANA and NAF at the national level;

• Policies, guidelines, protocols revised (IMAM, SAM, maternal nutrition);

• Assistance provided to nutrition and WASH Coordination Mechanisms at provincial levels to plan and coordinate activities across sectors to improve nutrition;

• Assistance provided to provincial-level structures (PPHD, PRRD, MAIL) to program, manage, and monitor nutrition and WASH services;

• PND’s (national and provincial level) core competencies in nutrition increased;

• Assistance provided to MoPH/PND to revise current short-term in-service IYCF training packages to ensure these align with best nutrition and WASH standards;

• BPHS NGOs’ staff (program managers, monitoring officers, nutrition officers) core competencies in nutrition increased;

• Frontline workers, such as CHW, community midwives, community nurses, agricultural extension workers, teachers, sanitation promoters, and other community volunteers, trained in essential nutrition and WASH actions;

• In-service nutrition and WASH training packages developed according to standards for a whole range of cadres beyond the health sector;

• in-service nutrition, sanitation, and hygiene training integrated in Public and private Afghan training institutions;

• In-service nutrition and WASH curricula developed and integrated in existing Afghan training institutions;

• Distance learning models tested for frontline workers.

Required indicators:

• Number of people trained in child health and nutrition;

• Number of people trained to improve hygiene behavior and sanitation practices;

47 Public Nutrition Department/MoPH: Assessment of Nutrition Interventions in the BPHS and EPHS. Final Report August 2014 48 PND Director’s discussions October 2014 49 The EU-funded assessment of nutrition services will serve as a baseline

• Number of health facilities with established capacity to manage acute malnutrition;50

• Number of children under five reached by the key nutrition services defined by the BPHS;

• Number of children under two reached by the key nutrition services defined by the BPHS;

• Percent of pregnant women who receive nutrition specific interventions during pregnancy according to protocols.51

Objective 2: Adoption of optimal nutrition and hygiene behavior increased at community and household levels (LOE: 40 percent)

To accomplish Objective 2, the Contractor must implement activities, identified through annual work plans, to achieve the following outcomes:

• Adoption of optimal maternal, infant, and young child nutrition behaviors improved

• Adoption of optimal water, sanitation, and hygiene behavior for a clean, safe household environment increased;

• Community-led responses to support rapid adoption of optimal maternal, infant, and young child nutrition and

WASH behaviors increased.

The Contractor must carry out innovative activities at community and household levels, leading to the sustainable, long-term adoption of optimal maternal, infant, and young children nutrition, hygiene, and sanitation behavior change, galvanizing community-led responses, increasing private sector engagement, and building women’s empowerment effectively, without creating “harm” within communities.

The Contractor must implement…