H4L_CORE_RFP 24April2012 .pdf

1. THIS CONTRACT IS A RATED ORDER RATING PAGE 3 OF139 PAGES

UNDER DPAS (15 CFR 700) N/A

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

SEALED BID (IFB)

NEGOTIATED (RFP)

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

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

9. Sealed offers in original and _____________________________ copies for furnishing 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 _______________________ (Hour) (Date)

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.

A. NAME B. TELEPHONE (NO COLLECT CALLS) C. E-MAIL ADDRESS

AREA CODE NUMBER EXT.

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

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

A SOLICITATION/CONTRACT FORM I CONTRACT CLAUSES

B SUPPLIES OR SERVICES AND PRICES/COSTS PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

C DESCRIPTION/SPECS./WORK STATEMENT J LIST OF ATTACHMENTS

D PACKAGING AND MARKING PART IV - REPRESENTATIONS AND INSTRUCTIONS

E X INSPECTION AND ACCEPTANCE 46

F DELIVERIES OR PERFORMANCE

G CONTRACT ADMINISTRATION DATA L INSTR., CONDS., AND NOTICES TO OFFERORS

H SPECIAL CONTRACT REQUIREMENTS M EVALUATION FACTORS FOR AWARD

K

REPRESENTATIONS, CERTIFICATIONS AND OTHER

STATEMENTS OF OFFERORS

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

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 price set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

13. DISCOUNT FOR PROMPT PAYMENT 10 CALENDAR DAYS (%) 20 CALENDAR DAYS (%) 30 CALENDAR DAYS (%) CALENDAR DAYS (%)

(See Section I, Clause No. 52-232-8)

14. ACKNOWLEDGEMENT OF AMENDMENTS AMENDMENT NO. DATE AMENDMENT NO. DATE

(The Offeror acknowledges receipt of amendments to the SOLICITATION for Offerors and related documents numbered and dated:

CODE FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME AND

ADDRESS

OF OFFEROR

(Type or print)

15B. TELEPHONE NUMBER 17. SIGNATURE 18. OFFER DATE

AREA CODE NUMBER EXT.

15C. CHECK IF REMITTANCE ADDRESS IS DIFFERENT FROM

ABOVE - ENTER SUCH ADDRESS IN SCHEDULE

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

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION: 23. SUBMIT INVOICES TO ADDRESS SHOWN IN ITEM (4 copies unless otherwise specified)

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

24. ADMINISTERED BY (If other than Item 7) 25. PAYMENT WILL BE MADE BYCODE CODE

26. NAME OF CONTRACTING OFFICER (Type or print)

Thomas M. Stephens, Regional Contracting Officer

27. UNITED STATES OF AMERICA 28. AWARD DATE

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

(Signature of Contracting Officer)

(REV. 9-97)

10. FOR INFORMATION CALL:

11. TABLE OF CONTENTS

STANDARD FORM 33

SOLICITATION, OFFER AND AWARD

SOLICITATION

OFFER (Must be fully completed by Offeror)

AWARD (To be completed by Government)

SOL-367-12-000002

X

24/04/2012

72000

Contracts Office USAID/Nepal US Embassy Maharajgunj, Kathmandu Nepal

See Section L.5

See Box 7 8 June 2012 4:00 P.M

Pradeep Neupane 977 1 4007200 4241 pneupane@usaid.gov

See Attached Table of Contents

X 3

X 7-8

X 9-44

X 45

X 47-51

X 52-55

X 56-68

X 68-86

X 87

X 88-100

X 101-115

X 116-119

$.00

72000

Contracts Office USAID/Nepal G.P.O. Box 295 U.S. Embassy, Maharajgunj, Kathmandu, Nepal

USAID/Nepal Office of Controller

Table of Contents Page

SECTION A - SOLICITATION/CONTRACT FORM 3

SF 33 - SOLICITATION OFFER AND AWARD 3

PART I - THE SCHEDULE 7

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS 7

B.1 PURPOSE 7

B.2 CONTRACT TYPE 7

B.3 ESTIMATED COST, FIXED FEE, AND OBLIGATED AMOUNT 7

B.4 BUDGET SCHEDULE 7

B.5 INDIRECT COSTS (DEC 1997) 8

B.6 ADVANCE UNDERSTANDING ON INDIRECT COSTS 8

B.7 COST REIMBURSABLE 8

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK 9

SECTION D - PACKAGING AND MARKING 45

D.1 AIDAR 752.7009 MARKING (JAN 1993) 45

D.2 BRANDING STRATEGY 45

D.3 OUTREACH 45

SECTION E - INSPECTION AND ACCEPTANCE 46

E.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE 46

E.2 INSPECTION AND ACCEPTANCE 46

SECTION F - DELIVERIES OR PERFORMANCE 47

F.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE 47

F.2 PERIOD OF PERFORMANCE 47

F.3 PERFORMANCE STANDARDS 47

F.4 REPORTS AND DELIVERABLES OR OUTPUTS 47

F.5 KEY PERSONNEL 49

F.6 PLACE OF PERFORMANCE 50

F.7 AUTHORIZED WORKDAY/WEEK 50

F.8 SUBMISSION OF DEVELOPMENT EXPERIENCE DOCUMENTATION 50

SECTION G - CONTRACT ADMINISTRATION DATA 52

G.1 AIDAR 752.7003 DOCUMENTATION FOR PAYMENT (NOV 1998) 52

G.2 ADMINISTRATIVE CONTRACTING OFFICE 53

G.3 CONTRACTING OFFICER’S TECHNICAL REPRESENTATIVE (COR) 53

G.4 TECHNICAL DIRECTIONS/RELATIONSHIP WITH USAID 53

G.5 PAYING OFFICE 54

G.6 ACCOUNTING AND APPROPRIATION DATA 55

SECTION H - SPECIAL CONTRACT REQUIREMENTS 56

H.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE 56

H.2 AIDAR 752.225-70 SOURCE AND NATIONALITY REQUIREMENTS (FEB 2012) 56

H.3 AIDAR 752.7004 EMERGENCY LOCATOR INFORMATION (JUL 1997) 57

H.4 SUBMISSION REQUIREMENTS FOR DEVELOPMENT EXPERIENCE

DOCUMENTS AIDAR 752.7005 57

H.5 INSURANCE AND SERVICES 58

H.6 AIDAR 752.228-70 MEDICAL EVACUATION (MEDEVAC) SERVICES (JULY 2007) 58

H.7 AUTHORIZED GEOGRAPHIC CODE 59

H.8 NONEXPENDABLE PROPERTY PURCHASES AND INFORMATION

TECHNOLOGY RESOURCES 59

H.9 LOGISTIC SUPPORT 59

H.10 LANGUAGE REQUIREMENTS 59

H.11 SUBCONTRACTING PLAN AND THE SF 294 – SUBCONTRACTING

REPORT FOR INDIVIDUAL CONTRACTS AND SF 295 – SUMMARY

CONTRACTING REPORT 59

H.12 SUBCONTRACTING CONSENT 60

H.13 PERSONNEL COMPENSATION 60

H.14 EMPLOYMENT COSTS OF THIRD COUNTRY NATIONALS AND

COOPERATING COUNTRY NATIONALS 61

H.15 EXECUTIVE ORDER ON TERRORISM FINANCING (FEB 2002) 61

H.16 FOREIGN GOVERNMENT DELEGATIONS TO INTERNATIONAL

CONFERENCES (JAN 2002) 61

H.17 REPORTING OF FOREIGN TAXES 61

H.18 ENVIRONMENT COMPLIANCE 62

H.19 HOMELAND SECURITY PRESIDENTIAL DIRECTIVE-12 63

H.20 SALARY SUPPLEMENTS FOR HG EMPLOYEES (OCT 1998) 64

H.21 USAID DISABILITY POLICY (DEC 2004) 64

H.22 VOLUNTARY POPULATION PLANNING ACTIVITIES (JUNE 2008) 64

H.23 CONDOMS (ACQUISITION) (JUNE 2005) 66

H.24 PARTICIPANT TRAINING AND EXCHANGE VISITORS 66

H.25 PROHIBITION AGAINST DISCRIMINATION (OCT 2011) 67

PART II - CONTRACT CLAUSES 69

SECTION I - CONTRACT CLAUSES 69

I.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE 69

I.2 52.203-13 CONTRACTOR CODE OF BUSINESS ETHICS AND CONDUCT (APR 2010) 71

I.3 52.204-01 APPROVAL OF CONTRACT (DEC 1989) 74

I.4 52.204-7 CENTRAL CONTRACTOR REGISTRATION (Apr 2008) 74

I.5 52.204-10 REPORTING EXECUTIVE COMPENSATION AND FIRST-TIER

SUBCONTRACT AWARDS (JUL 2010) 76

I.6 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (FEB 2012) 78

I.7 52.209–9 UPDATES OF PUBLICLY AVAILABLE INFORMATION REGARDING

RESPONSIBILITY MATTERS (FEB 2012) 79

I.8 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999) 80

I.9 52.222-50 COMBATING TRAFFICKING IN PERSONS (FEB 2009) 80

I.10 52.227-23 RIGHTS TO PROPOSAL DATA (TECHNICAL) (JUN 1987) 81

I.11 52.229-8 TAXES—FOREIGN COST-REIMBURSEMENT CONTRACTS (MAR 1990) 81

I.12 52.232-25 PROMPT PAYMENT (OCT 2008) 82

I.13 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998) 85

I.14 AIDAR 752.7032 INTERNATIONAL TRAVEL APPROVAL AND NOTIFICATION

REQUIREMENTS (JAN 1990) 85

I.15 752.242-70 PERIODIC PROGRESS REPORTS (OCT 2007) 86

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHMENTS 87

SECTION J - LIST OF ATTACHMENTS 87

PART IV - REPRESENTATIONS AND INSTRUCTIONS 88

SECTION K - REPRESENTATIONS, CERTIFICATIONS AND OTHER STATEMENTS

OF OFFERORS 88

K.1 NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY

REFERENCE 88

K.2 52.204-8 ANNUAL RERESENTATIONS AND CERTIFICATIONS (JAN 2006) 88

K.3 52.204-3 TAXPAYER IDENTIFICATION (OCT 1998) 91

K.4 52.204-6 DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER (APR 2008) 92

K.5 52.204-7 CENTRAL CONTRACTOR REGISTRATION (FEB 2012) 92

K.6 52.230-1 COST ACCOUNTING STANDARDS NOTICES AND

CERTIFICATIONS (OCT 2008) 94

K.7 52.230-7 PROPOSAL DISCLOSURE –COST ACCOUNTING PRACTICE CHANGE

(APR 2005) 96

K.8 INSURANCE - IMMUNITY FROM TORT LIABILITY 96

K.9 52.209-5 CERTIFICATION REGARDING RESPONSIBILITY MATTERS (JAN 2011 2010) 96

K.10 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (FEB 2012) 98

K.11 52.209-9 UPDATES OF INFORMATION REGARDING

RESPONSIBILITY MATTERS (JAN 2011) 99

K.12 SIGNATURE 99

SECTION L - INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS 101

L.1 NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY

REFERENCE 101

L.2 52.215-1 INSTRUCTION TO OFFERORS – COMPETITIVE ACQUISITION

(JAN 2004) 101

L.3 52.216-1 TYPE OF CONTRACT (APR 1984) 104

L.4 52.233-2 SERVICE OF PROTEST (SEP 2006) 104

L.5 GENERAL INSTRUCTIONS TO OFFERORS 105

L.6 INSTRUCTIONS FOR THE PREPARATION OF THE TECHNICAL PROPOSAL 106

L.7 INSTRUCTIONS FOR THE PREPARATION OF THE BRANDING

IMPLEMENTATION PLAN (BIP) 107

L.8 INSTRUCTIONS FOR THE PREPARATION OF THE COST PROPOSAL 111

L.8.1 SUBMISSION INSTRUCTIONS 111

L.8.2 GENRAL ASSUMPTIONS AND OTHER INSTRUCTIONS 114

SECTION M - EVALUATION FACTORS FOR AWARD 116

M.1 GENERAL INFORMATION 116

M.1.1 SOURCE SELECTION 116

M.1.2 AWARD WITHOUT DISCUSSIONS 116

M.1.3 EVALUATION OF TECHNICAL PROPOSALS 116

M.1.4 EVALUATION OF COST PROPOSALS 116

M.2 TECHNICAL EVALUATION CRITERIA 117

M.2 DETERMINATION OF THE COMPETITVE RANGE AND CONTRACT AWARD 119

M.3 CONTRACTING WITH SMALL BUSINESS CONCERNS AND

DISADVANTAGED ENTERPRISES 119

ATTACHMENTS

ATTACHMENT 1: IDENTIFICATION OF PRINCIPAL GEOGRAPHIC CODES 120

ATTACHMENT 2: ACRONYMS 121

ATTACHMENT 3: OFAC LICENSE NO. SDGT-760f 123

ATTACHMENT 4: BLANKET WAIVER ON MOTOR VEHICLES 126

ATTACHMENT 5: LIST OF AVAILABLE EQUIPMENT 130

ATTACHMENT 6: POPULATION AND ACTIVITIES IN H4L DISTRICTS 139

PART I - THE SCHEDULE

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

B.1 PURPOSE

The purpose of this contract is to provide technical assistance as described in detail in Section C, Statement of Work.

B.2 CONTRACT TYPE

This is a Cost-Plus-Fixed-Fee (CPFF) completion-type, cost reimbursement contract. For the consideration set for the below, the Contractor shall provide the deliverables or outputs described in Section C and F and comply with all contract requirements.

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 is TBD. The estimated cost plus fixed fee is TBD.

(b) Within the estimated cost plus fixed fee specified in paragraph (a) above, the amount currently obligated and available for reimbursement of allowable costs incurred by the Contractor (and payment of fee, if any) for performance hereunder is TBD. The Contractor shall not exceed the aforesaid obligated amount.

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

B.4 BUDGET SCHEDULE

COST ELEMENTS Year 1 Year 2 Year 3 Year 4 Year 5 Total Salaries and Wages Fringe Benefits Consultants Travel and Transportation Allowances Equipment and Supplies Program Costs Monitoring and Evaluation Subcontracts Windows of Opportunity Other Direct Costs Indirect Costs Total Estimated Cost Fixed Fee TOTAL Estimated Cost Plus Fixed Fee

Note: Individual subcontractors should include the same cost element breakdowns in their budgets.

B.5 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 or predetermined rates and the appropriate bases:

Description Rate Base Type Period

1/ 1/ 1/

[To be determined]

B.6 ADVANCE UNDERSTANDING ON CEILING INDIRECT COST RAT ES AND FINAL

REIMBURSEMENT FOR INDIRECT COSTS

(1) Reimbursement for allowable indirect costs shall be at final negotiated rates but not in excess of the following ceiling rates:

Description Rate Base Type Period 1/ 1/ 1/

[To be determined]

(2) 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.

(3) The Government shall not be obligated to pay any additional amount on account of indirect costs above the ceiling rates established in the contract.

(4) This understanding shall not change any monetary ceiling, obligation, cost limitation, or obligation established in the contract.

B.7 COST REIMBURSABLE

The U.S. dollar costs allowable shall 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.

[END OF SECTION B]

SECTION C - STATEMENT OF WORK

C.1 INTRODUCTION

The United States Agency for International Development Mission to Nepal (USAID/Nepal) seeks to secure technical services for the implementation of a new Health for Life (H4L) activity. The purpose of the contract is to strengthen the GON capacity to plan, manage and deliver quality and equitable family planning and maternal, newborn, and child health services.

The H4L activity builds on accomplishments gained from USAID/Nepal’s health sector investment to date with a greater focus on health systems strengthening and measuring progress in systems improvements.

The principal development hypothesis underlying this activity is that the Government Of Nepal’s (GON) capacity to plan, manage and deliver high quality and equitable family planning, maternal, newborn and child health services can be greatly improved with cross-cutting health system strengthening interventions. H4L interventions directly address key health system constraints in the following areas:

local health systems governance; data for decision-making and evidence-based policy development, human resources; quality improvement systems; logistics systems; and, knowledge and behavior change.

In addition to these cross-cutting areas of focus, H4L will work in 14 districts to improve access to and knowledge of maternal newborn, child health and family planning services. USAID’s investment in these 14 districts will complement USAID’s other activities and will serve as a learning lab for nation-wide systems improvements.

The focus of H4L was strongly influenced by consultation with the Ministry of Health and Population (MOHP) and other stakeholders such as external development partners and the lessons learned from the evaluation of the Nepal Family Health Program (NFHP II) as well as the extensive analyses conducted for the development of the Nepal Global Health Initiative (GHI) Country Strategy and related action plans (please see reference documents under: http://nepal.usaid.gov/downloads/all-downloads/category/1-health-and-family-planning.html). The activity1 will be results-oriented and integrated with USAID’s development assistance in health, nutrition and other sectors. The H4L activity will complement the GON National Health Sector Programme II (NHSP II) for 2010-2015 and will embrace new US government initiatives and reforms, including the GHI and the USAID Forward procurement reforms (see H4L reference documents under: http://nepal.usaid.gov/downloads/all-downloads/category/1-health-and-family-planning.html).

C.2 CONTEXT

C.2.1 Overview: This activity will fit within and contribute to achieving the goals of three major strategies

– the GON’s NHSP II, USAID’s Foreign Assistance Strategic Framework for Nepal and the US Government’s GHI Strategy. As one of the key contributors to the GHI in Nepal, the H4L activity will collaborate with USAID/Nepal’s health projects and other USG agencies and partners – including the Centers for Disease Control, the Department of Defense, Department of State, and the National Institutes of Health to achieve the GHI goals. H4L fills an important niche in the USG support to the health sector in Nepal by focusing on strengthening the health system, which will help ensure that all other USG technical assistance and collaboration efforts pay long-term dividends.

This activity will take a systematic approach to strengthening GON systems and institutionalizing best practices at the local, district and national levels. The unifying theme is that of capacity development of the public health system, measuring and monitoring progress, and making the necessary change along the way to ensure that the capacity related activities result in lasting change. H4L is aligned with the

1 USAID recently revitalized its Project Design Process as described in the following guidance:

http://www.usaid.gov/our_work/policy_planning_and_learning/documents/PD_Guidance_Final.pdf. Please also see the definition of activity, project and program in the ADS 200 series: http://www.usaid.gov/policy/ads/200/. H4L is the main activity nested in a project focused on health systems strengthening and improved data for decision-making. This project fits within USAID/Nepal’s larger health sector program.

Potter/ Brough model2 below, which postulates that capacity development falls short when it only focuses on tools and skills. It must also encompass improvements especially on strengthening the structure, systems and roles that support the institutional change being sought.

This activity will collaborate with other USAID/Nepal development sector teams and their partners to achieve the goals of the other Presidential Initiatives such as Feed the Future (FtF). The GHI strategy specifically links with the FtF Initiative through their common objectives in the area of nutrition. Principles of both the GHI and FtF are reflected in H4L through country ownership, sustainability and health systems strengthening, a focus on women, girls and gender equality, metrics, monitoring and evaluation, and innovation and research.

USAID has embarked on a comprehensive effort to reform foreign assistance modality. This reform agenda, known as USAID Forward, 3 aims to change the way the Agency does business-- including diversifying partnerships, an emphasis on country ownership and leadership, innovation, and a relentless focus on results. USAID/Nepal made an important contribution to the USAID Forward objectives in 2010 when, for the first time, it signed a Joint Financing Arrangement (JFA) with the MOHP and other donors.

While not a legally binding document, this mechanism provided for transparency, better donor coordination and improved the MOHP’s ability to plan more effectively. Currently underway is a Joint Technical Assistance Arrangement (JTAA) that will be signed by the MOHP, the USG and other donors that provide technical assistance through parallel channels. The JFA and JTAA represent important tools for strategic coordination and integration, strengthening partnerships, encouraging country ownership, investing in country-led plans, and building sustainability through health systems strengthening. The H4L activity is in-line with USAID Forward principles through its focus on capacity building of host country systems and its focus on measurement and results.

C.2.2 USAID/Nepal’s Health Program: The Nepal Family Health Program (NFHP) II is currently USAID/Nepal’s flagship program to address family planning and maternal, newborn and child health but is scheduled to end in September 2012. NFHP II works in 22 districts throughout the country. NFHP II’s goal is to improve the delivery and use of basic public sector family planning, maternal, newborn, child health, and literacy/life skills services, in a manner that builds local capacity and encourages stakeholder collaboration. This includes working with the Female Community Health Volunteers who deliver most of the services at the community level. Working with the government at national and district levels, NFHP II

2 “Systematic capacity building: a hierarchy of needs”, Potter, C. and Brough, R., Health Policy and Planning 19(5): 336–345, Oxford Press, 2004.

3 See http://forward.usaid.gov/ is improving policy; strengthening leadership and management capacity; improving service delivery;

spearheading innovative approaches in community-based maternal and newborn care, including nutrition;

and increasing community participation in health decisions and activities. H4L builds on the successes and lessons learned from NFHP II, as identified through a recent program evaluation (please see reference documents under: http://nepal.usaid.gov/downloads/all-downloads/category/1-health-and-family-planning.html).

USAID/Nepal’s social marketing program, the Ghar Ghar Maa Swasthya (GGMS) program assists the GON in expanding the depth, reach, and impact of the private sector in social marketing, by providing a low-cost supply of maternal/child health, family planning, and HIV-prevention products and services.

GGMS focuses on underserved and most-at-risk populations, scaling up promising rural and community-based marketing initiatives, and engaging non-governmental organizations and commercial distributors to increase product accessibility in hard-to-reach areas. Both GGMS and H4L will concentrate on the hard-to-reach regions and populations in the areas of family planning and maternal, newborn and child health.

GGMS will continue to develop the private sector while H4L will focus on the public sector.

USAID/Nepal recently awarded a five-year, $46 million integrated nutrition program, Suaahara, which will improve the nutritional status of women and children during the most critical period (pregnancy to two years of age) through a comprehensive facility and community-based nutrition program targeting the most vulnerable in Nepal. H4L will also promote essential nutrition actions, such as relevant hygiene messages, in districts beyond those covered under Suaahara and FtF.

USAID/Nepal also recently awarded a five-year, $27.5 million HIV/AIDS program, Saath-Saath, which will reduce transmission and the impact of HIV/AIDS, and improve reproductive health among select, most-at risk populations. H4L will work with Saath-Saath to integrate the HIV/AIDS and health commodity logistics systems for improved efficiency.

C.2.3 Other Donors and Related Programs: A Health Sector Wide Assistance Program (SWAp) was first organized in 2004. It involved most health development partners with the aim of harmonizing all input (e.g. funds, technical assistance, commodities) into an MOHP-led program. Currently, the donors providing pooled funding under the SWAp are the World Bank, the U.K. Department for International Development (DFID), KfW and the Australian Agency for International Development (AusAID) for activities in the national plan. A DFID-funded program, the Nepal Health Sector Support Programme (NHSSP), provides technical assistance to the MOHP for activities in the NHSP II on behalf of the pooled partners. The non-pooling partners, such as USAID/Nepal, are also active SWAp participants and ensure that their programs are in direct support of the national plan. All partners participate in the MOHP-organized biannual progress reviews and meet regularly to ensure coordination.

Several donors are supporting the MOHP’s family planning and maternal and child health programs in Nepal including the World Bank, DFID, AusAID, UNICEF, UNFPA, World Food Program, WHO and the Japanese International Cooperation Agency (JICA). While other health donors focus more on the central level or health facilities, USAID/Nepal’s efforts have long supported community-based services to improve access, quality and utilization of services that are linked to health facilities.

C.3 BACKGROUND

C.3.1 Overview: Nepal, with a population of 30.5 million, is among the poorest countries in the world, as measured in the Human Development Report 2011. Nepal’s social indicators are low for the South Asia region: more than 30% of the Nepalese population lives below the national poverty line (Ministry of Finance, 2006); female (15-49 years) literacy rate is 55%, compared to the male (15-59 years) literacy rate of 81%. Women have a lower social status than men and gender inequalities are deeply rooted.

More boys than girls receive any form of education. Women generally work longer hours than men and men have better access to services, including health. Almost one-quarter of Nepalese women have given birth before reaching age 18, while over half have given birth by age 20. The health system continues to be plagued by weak financial systems, lack of qualified permanent staff, and misallocation of resources.

C.3.2 Health Care System: Nepal is divided into five Development Regions (Far-Western, Mid-Western, Western, Central and Eastern) with a hierarchy of 14 zones, 75 districts, 58 municipalities, and 3,915 Village Development Committees (VDC). The base of the public health system is at the VDC level, where either a health post or sub-health post has been established and is usually staffed by a village health worker and a maternal and child health worker. Primary healthcare centers, generally at the district level, are the lowest level of the system staffed by a doctor. District and zonal hospitals are the next referral point in the public health system. Municipalities are expected to set-up their own public health system;

however many municipalities do not have any health facilities or lack urban clinics. At the central level in Kathmandu, the Department of Health Services (DOHS), a department within MOHP at the Kathmandu level, has responsibility for developing and implementing policies and guidelines, financial planning and management, and most in-service training. The current health governance system is expected to change under the anticipated decentralization in Nepal although exact plans have not been set (see Section C.4.1).

The GON’s vision for the health sector is to improve the health and nutritional status of the Nepali population, especially for the poor and excluded. Yet the health sector continues to face ongoing challenges in improving the situation of these disadvantaged groups, namely, through lowering barriers to healthcare access, raising the quality of services and ensuring the availability of medicines. The health system is understaffed, especially in the mountain and hill areas that are hardship posts for government personnel. To improve service accessibility in these remote areas the GON has developed Remote Area Guidelines that includes a special focus on safe motherhood in Nepal. Additionally, the Second Long Term Health Plan 1997 – 2017 addresses disparities in healthcare by aiming to improve equitable community access to quality health care services in rural areas. It describes improving the health status of the most vulnerable groups, particularly those whose health needs often are not met - women and children, the rural population, the poor, the underprivileged and the marginalized populations. This is also reflected in the NHSP II (2010-2015) to improve health outcomes by expanding access to and increasing the use of essential health care services especially for the poor with a nationwide coverage. In accordance with these guidelines, Nepal has developed a strong community-based health response, which includes 48,000 FCHVs.

C.3.3 Progress to Date: Nepal is on track to meet Millennium Development Goals (MDGs) 4 and 5 related to maternal and child health respectively, as shown in Table 1. The average number of children a woman has in her lifetime has declined from five births per woman in 1996 to 2.6 in 2011, greatly improving the health of women and children. Though nutrition falls under the MDG Goal 1 “Eradicate extreme poverty and hunger,” it is inextricably linked to maternal and child health. While some progress has been made, there are still significant challenges related especially to reducing the prevalence of stunting among children. Tuberculosis case detection and treatment success rates are improving and malaria annual parasite incidence is declining. HIV/AIDS remains a concentrated epidemic with continuing risks associated with several high risk groups including a large migrant worker population.

However, HIV screening and treatment services are expanding and behavior change communication programs are increasing access to information about prevention.

Table 1: Trends in selected indicators of reproductive, maternal, and child health (green: target met/maintained; yellow: target may be met; red: target may be met with greater/focused investments) Indicator 1996 2001 2006 2011 2015

Target Under-five mortality rate (per 1,000 live births) 118 91 61 54 54 Infant mortality rate (per 1,000 live births) 79 64 48 46 36 Newborn mortality rate (per 1,000 live births) 50 39 33 33 16 One-year old children fully immunized (%) 43 66 83 87 85 Maternal mortality ration (per 100,000 live births)

539 415 281 - 134

Births attended by skilled birth attendants (%) - 11 19 36 60

Underweight children under five (%) - 43 39 29 29

The success from 2004 - 2010 was due in large part to resources from the health donors who supported nearly half of all GON spending on health. GON health expenditures is 5.8% of GDP (2009), and the combined public and private per capita spending on health is US$18 (2006), of which fifty-five percent of that total was from out-of-pocket spending by households. Budget allocations for essential health care services that benefit the greatest proportion of the population have improved over time from 65% of the total health budget in FY 2004/5 to 75% in FY 2009/10, which is a positive indication of the GON’s priorities.4 The MOHP organizes and budgets for its programs in accordance with the targets and priorities set forth in its national plan, the NHSP II. However, given the overall low GON expenditure on health, it is clear that the support of the donor community will need to continue in order to attain its goals.

USAID/Nepal’s support to the MOHP’s central, regional and district level authorities over the past several decades has led to significant improvements of the logistics management system. Some of these system advances include reductions in stock-outs of key commodities (e.g. contraceptives, clean home delivery kits, oral rehydration salts and zinc for diarrhea in children), development of a strong logistics management information systems (LMIS) which now has reporting coverage exceeding 95% nationwide, roll-out of a web-based LMIS system to all 75 districts of Nepal, and enhanced GON capacity for procurement and forecasting. Further, the “pull” system, demand-based logistics distribution which reduces waste, has been rolled-out nationwide to the district and regional levels.

C.4 PROBLEM STATEMENT

C.4.1 Over the past decade, Nepal has made tremendous strides in health indicators and health system improvements (see section C.3.3.). However, Nepal’s health system continues to face severe constraints to extending equitable, accessible and affordable services to the population. The following are challenges central to the health system which will impact and be impacted by H4L.

Governance of the health system: Changes to the current federal government system that would support decentralization and improve local oversight of health services are anticipated under Nepal’s future constitution. Local governance of health services and community involvement lead to increased levels of accountability and responsiveness to the local needs and conditions. Nepal’s highly diverse geography and cultures make local oversight particularly important. While the GON has made progress in decentralization through initiatives in the logistics system and promotion of health facility management operations committees and FCHVs, much more could be done to improve local ownership and oversight over health.

The quality and timeliness of the information generated by the Health Management Information System (HMIS) in Nepal has improved significantly over the years and Nepal is renowned as a hub of quality research on successful community-based health interventions. However, the capacity of the MOHP to use HMIS and research findings for decision-making remains weak. Strong and sustainable health systems depend on the effective use of information and research to develop or refine national health policy and to guide and manage health systems, whether public or private. Collecting and analyzing health data is also the key to tracking equitable access and utilization of health services, and taking action to correct problems.

As part of the commitment to increasing country ownership and promoting host country systems, USAID/Nepal hopes to expand its direct financial support to the MOHP in the future. In order for USAID to increase direct funding, the MOHP needs to have a rigorous and transparent audit system to strengthen financial management capacity at all levels. As part of its stewardship role over the entire health sector, the MOHP would further benefit from the ability to contract out services and work more closely with the growing private sector in Nepal. Currently no functional policy framework or legal

4 National Health Sector Programme (NHSP) II, (2010-2015), Ministry of Health and Population, 7 April 2010.

provision exists in the MOHP for partnering with the private sector including contractual services, quality assurance, monitoring of service provisions and reporting arrangements.5

Human resources for health: The GON and all EDPs recognize that the shortage of trained human resources, inequity in the distribution of qualified health personnel, and absenteeism, particularly in hill and mountain districts, severely constrain Nepal’s health system. These deficiencies are a major challenge to the universal health service coverage GON aims to provide, particularly in remote areas.

Because of political turmoil, the MOHP is unable to create new positions needed to update and deploy its human resources effectively. Furthermore, the low quality of pre-service training for maternal and child health leads to costly retraining. Insufficient clinical skills among newly graduated Auxiliary Nurse Midwives (ANMs), one of the main providers in Nepal of safe delivery, is a particular concern as the demand for facility births increases.

Quality of health services: Nepal has made great strides in improving the availability of services through its community based programs as well as expansion of key family planning and maternal, newborn and child health services available at sub-health posts, health posts and primary health care centers. Great progress is also evident with the improved availability of essential drugs and commodities at the facility and community levels. There are still substantial challenges, however, with ensuring that the services offered, especially at the most peripheral health facilities, are of adequate quality and providers are sufficiently skilled. For example, the NFHP II Evaluation identified an urgent need to help assure the quality of obstetrical and newborn care at the health post and sub-health post level where the number of birthing rooms is increasing exponentially, due to the new GON “Aama” program which gives incentives to providers and clients for facility delivery. The following are common examples of factors affecting the quality of services: poor infection prevention practices, lack of adequate water supplies and cleaning materials, limitations in space which affect privacy for counseling, and little motivation to follow existing standards of care.

Progress has also been made to develop components of a national quality improvement program but the national integrated supervision system remains unlinked to any system that ensures these standards of care or guidelines are being applied. There is no system in place that allows facilities or district health offices to conduct self-assessments and/or external assessments or accreditation related to the quality of health facility management functions or the adherence to clinical standards.

Access to health services: Utilization of health services has increased but progress has been uneven.

Over the past five years disparities among castes, ethnicities, and wealth quintiles have decreased in contraceptive use, childhood immunization, diarrheal disease control, and treatment for acute respiratory infection. Differences between castes, ethnic groups, and wealth quintiles in birth weight or size at birth and under-five and infant mortality rates have also decreased. However, disparities in maternal care increased – the wealthiest women are still 12 times more likely to use a trained health worker during delivery than the poorest. Differences in infant mortality rates between advantaged and disadvantaged population groups have also increased. Addressing these disparities is integral to achieving the GON’s targets for reduction of infant and maternal mortality; the trends in these rates are currently headed in the right direction, but the targets will not be met without continued focus and effort.

Knowledge about health and how to access health services is tied to increased use of health services.

Knowledge among the general population in Nepal about topics such as family planning and newborn care, as well as utilization of antenatal care and delivery services, increased significantly between 2006 and 20116. The National Health Education, Information and Communication Centre developed a National Family Planning Communications Strategy with assistance from other health donors and USAID/Nepal, which is now in place, and there is a range of Information Education and Communication/Behavior

5 Opportunities, Challenges and Obstacles in Implementation of Nepal Health Sector Program Implementation Plan II, Health Sector Reform Unit, MOPH, January 2010

6 NDHS 2006 and 2011 NDHS Preliminary Report

Change Communication print materials for use throughout the country. Despite these efforts, there remain populations underserved by communication activities such as adolescent boys and girls and their caretakers; marginalized castes; geographically isolated populations; and women.

The knowledge and interpersonal skills of different health workers and volunteers also plays a big role in utilization of services. This includes FCHVs, who may be the only health care provider some people see, though they are community level volunteers that provide a crucial, but limited range of services. Many FCHVs do not have adequate skills to provide intensive and timely interpersonal counseling sufficient to produce the changes in behaviors and practices that will enable mothers to protect their own health as well as the health of their young children. To ensure adequate support and supervision for these FCHVs, other community health workers also need to be trained and mobilized to improve interpersonal communication between health workers and clients.

C.4.2 External factors: Geographic barriers and political instability are two key external factors that have a direct impact on health system performance. Nepal’s extremely challenging geography and topography limits transportation and communication options where need is greatest. The Nepal Living Standards Survey 2010/117 estimates an average of 73.8 percent of households have access to a health center within 30 minutes travel time nationally, but in mountain areas this falls dramatically.

Some districts are unreachable by vehicular traffic for up to six months of the year. Additionally, Nepal is currently in the process of amending its constitution, which will create a federalist state with a redefinition of political units below the national level. The anticipated federal structure will affect every area of the health system, from planning to service delivery to overall health governance. Because thee process is progressing slowly, there is much uncertainty about the future organization of governmental entities below the national level or how development programs will fit into these new levels of government.

C.5 ROLES

C.5.1 Leadership Role of the Government of Nepal The primary role of the GON through the MOHP is to implement its NHSP II 2010-2015. The GON will provide overall policy guidance for the activities outlined below and local GON authorities (e.g., district and lower level health officials) will also play a key role in ensuring the coordination of the various actors within their areas of authority, including those supported under this contract. Critical to this contract is the collaboration between the MOHP and H4L to ensure institutionalization of capacity in those health systems areas targeted for improvement. The annual progress reviews, semi-annual joint approval reviews held by the GON and weekly meetings of external development partners will be the key coordination mechanism for ensuring USAID activities and results are widely shared with key stakeholders in the sector.

C.5.2 USAID

The USAID office responsible for the direction and management of this activity is the Office of Health and Family Planning. The HFP Office, through the Contracting Officer’s Representative (COR), will provide overall technical direction on technical, management and policy issues relating to the achievement of results. HFP will also promote and monitor progress on GON policy initiatives affecting activity implementation and ensure coordination with other donor-funded programs.

USAID is committed to building capacity within the MOHP and to strengthening synergies between health activities in Nepal. In addition to providing oversight to H4L, USAID will track opportunities for partnership between H4L and other USG-funding activities including those that fall under the Feed the Future and Global Climate Change Initiatives. HFP will also manage an award to strengthen the logistics system in Nepal during the same timeframe as H4L. USAID will direct the Contractor to provide technical assistance to its logistics activity in the areas of management and coordination on a limited basis as

7 Nepal Living Standard Survey: Summary Report 2010/11, Central Bureau of Statistics, 2011 needed. USAID will continue to provide direct Redbook funding to the GON and will pursue opportunities to strengthen GON financial capacity to accept and effectively manage additional funds.

C.5.3 Contractor Due to the breadth of skills required, the Contractor must form a consortium with NGOs that are already working in Nepal. The Contractor should use no more than two international organizations. The Contractor must provide technical expertise in health systems strengthening including logistics management, health information and policy development, quality improvement and health governance as well as the health service delivery areas of family planning, maternal, newborn and child health, nutrition, interpersonal communication and counseling skills, mass media and behavior change programs. The Contractor must work with the GON at all levels to engage in collaborative work planning for health across government ministries involved in local health governance. In addition, the Contractor will be required to purchase and distribute a limited amount of commodities and supplies related to delivery and newborn health services, tablet PCs and handheld devices for data collection and reporting, computer and office equipment, etc.

The Contractor must serve the critical role of working explicitly on capacity development of Nepali government entities especially at the district and sub-district levels, and measuring improved capacity among those partners to conduct the work of the activity at the grassroots level.Capacity building may include strengthening GON and MOHP public financial management systems to manage health resources, including USAID funds, in the future. For the outputs described below, the Contractor must develop a timetable and a set of capacity development benchmarks to be met over the five years of the activity. The timetable and benchmarks must be established in collaboration with relevant MOHP departments and divisions at the national and district levels. Developing such benchmarks will help USAID/Nepal and the MOHP determine the extent to which improvements are being institutionalized over the course of this activity and identify whether certain activities need to be changed for better results.

Benchmarks must involve a variety of actions such as: the establishment of systems to carry out core functions, issuance of needed policy guidelines, undertaking periodic external assessments or audits, and other such measures to address the impediments to institutionalization of key programs. These benchmarks will also help make explicit some of the conditions needed to ensure that health donors support results in sustainable change and a reduction in Nepal’s reliance on external partners.

USAID plans to award a separate contract to a Nepali organization to build the capacity of the MOHP Logistics Management Division (LMD). During the first three years of the logistics contract, the H4L Contractor must provide technical assistance in the areas of management, monitoring and evaluation, and coordination to USAID’s H4L logistics contractor. . After the three years, the H4L Contractor must provide limited technical assistance for monitoring. Ensuring availability of the commodities, training health workers and other components of implementing the logistics activity will not be the responsibility of the H4L Contractor. After award of the H4L contract and logistics contract, USAID and the Contractor will determine the precise duration and scope of this technical assistance.

The H4L Contractor must provide a supplemental work plan to the Redbook (GON budget) to ensure the GON can track USAID’s complementary investments in the areas of MNCH/FP and health systems strengthening. USAID’s direct Redbook funding will be used to support activities under H4L; therefore, the H4L Contractor must work with the GON to ensure timely and appropriate disbursement of budgeted Redbook funds.

Finally, as opportunities arise, the Contractor may establish public-private partnerships to generate contributions through local agencies and community contributions, donations from private firms, and other sources of non-USG resources (see Section C.11.4).

C.6 OUTPUTS AND INDICATORS

H4L will contribute to improvements in the following high-level indicators:

Under-five mortality rate Infant mortality rate Neonatal mortality rate Maternal mortality rate Total fertility rate Health information system performance index Health service readiness index Proportion of health facilities offering specific services Proportion of GON managed health sector budget Disparity between richest and poorest quintiles.

The success of the Contractor will be directly measured against the following outputs:

Output 1: Improve health system governance of district health offices and sub-district level facilities Output 2: Develop and implement national evidence-base policy Output 3: Strengthen national level stewardship of the health sector Output 4: Institutionalize nation-wide system for quality improvement Output 5: Improve capacity of district and local level health workers and community volunteers to deliver high quality FP/MNCH and nutrition services Output 6: Improve knowledge, behavior and use of health services among target population Output 7: Strengthen capacity of USAID’s contractor for a logistical support activity strengthened

For each of the Outputs listed above and described below, the Contractor must develop, in coordination with relevant GON counterparts, an annual capacity building plan that includes a description of current health system capacity in each area, capacity targets for the year and measurable benchmarks against which to track success. Achievement of capacity building outputs will be another important area against which the Contractor will be evaluated.

The following sections provide more information about the background and aim of activities for each result, as well as expected deliverables and illustrative indicators.

C.6.1 Output 1: Improve health system governance of the district health offices and sub-district level health facilities.

C.6.1.1 Overview The central aim of this output is to build organizational capacity within the MOHP to support decentralization and local governance of health services. For this output the Contractor must perform two inter-related activities: (1) assist district officials to expand and strengthen Health Facility Operations and Management Committees (Facility Management Committees) composed of community leaders and citizens, including women, disadvantaged castes and minority groups and, (2) support the expansion of the GON’s Local Health Governance Strengthening Program (Governance Program) to build the capacity of local government officials to manage health care services.

The community level Facility Management Committees empower community members to hold GON and health providers accountable for the services they are supposed to provide and also offers an avenue for the community’s active participation in improving health facility operations and thus their own health status. USAID/Nepal’s support to the Governance Program pilot activity in two districts was instrumental in providing conceptual insights to the government in developing the local health governance strengthening program. This kind of policy scale-up and programmatic input will be even more crucial as the country moves forward with decentralization and devolution of health programs over the next five years. The H4L Contractor must build on the work of NFHP II to strengthen the role of local governance in building a stronger health system.