SOL-391-16-00003.pdf

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1. THIS CONTRACT IS A RATED ORDER RATING PAGE OF PAGES

UNDER DPAS (15 CFR 700)

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

SEALED BID (IFB) See Cover Page

NEGOTIATED (RFP)

7. ISSUED BY

Office of Acquisition and Assistance Same as Item 7.

USAID, Ramna 5 Diplomatic Enclave, Islamabad, Pakistan.

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 0 copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if handcarried, in the depository located in local time: SEE COVER LETTER (Hour)

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

X A SOLICITATION/CONTRACT FORM X I CONTRACT CLAUSES

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

X C DESCRIPTION/SPECS./WORK STATEMENT X J

LIST OF ATTACHMENTS

X D

PACKAGING AND MARKING PART IV - REPRESENTATIONS AND INSTRUCTIONS

X E

INSPECTION AND ACCEPTANCE

X F

DELIVERIES OR PERFORMANCE

X G

CONTRACT ADMINISTRATION DATA

X L

INSTR., CONDS., AND NOTICES TO OFFERORS

X H

SPECIAL CONTRACT REQUIREMENTS

X M

EVALUATION FACTORS FOR AWARD

X 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 (%)

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 OFFER 15A. 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 BY CODE CODE

26. NAME OF CONTRACTING OFFICER (Type or print) 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:

Saulat Rehan (9251) 2015008 srehan@usaid.gov

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)

N/A 1 136

RFP No.:391-16-00003 REQ-391-16-000011 X

See Attached Table of Contents

TABLE OF CONTENTS

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

B.1. PURPOSE

B.2. CONTRACT TYPE

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

B.4. BUDGET

B.7. PAYMENT OF FIXED FEE

B.8. CANCELLATION DATES AND CEILING

SECTION C– STATEMENT OF WORK

C.1 PURPOSE

C.2. BACKGROUND

C.3 PROJECT OPERATING APPROACH

C.4 PROGRAM COMPONENTS

C.5 GENDER CONSIDERATIONS

C.6 SUSTAINABILITY CONSIDERATIONS

C.7 ACTIVITY MONITORING AND EVALUATION PLAN

SECTION D - PACKAGING AND MARKING

D.1. AIDAR 752.7009 MARKING (JAN 1993)

D.2. BRANDING

SECTION E - INSPECTION AND ACCEPTANCE

E.1. NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

E.2. INSPECTION AND ACCEPTANCE

SECTION F - DELIVERIES OR PERFORMANCE

F.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

F.2 PERIOD OF PERFORMANCE

F.3 PLACE OF PERFORMANCE

F.4 PERFORMANCE STANDARDS

F.5 KEY PERSONNEL

F.6 PERSONNEL

F.7 AUTHORIZED WORK DAY/WEEK

F.8 AIDAR 752.242-70, PERIOD PROGRESS REPORTS (OCT 2007)

F.9 REPORTS

SECTION G - CONTRACT ADMINISTRATION DATA

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

G.2. ADMINISTRATIVE CONTRACTING OFFICE

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

G.4. TECHNICAL DIRECTIONS/RELATIONSHIP WITH USAID

G.5. PAYMENT INSTRUCTIONS

G.6. ACCOUNTING AND APPROPRIATION DATA

SECTION H - SPECIAL CONTRACT REQUIREMENTS

H.1. NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

H.2. AIDAR 752.7004 EMERGENCY LOCATOR INFORMATION (JUL 1997)

H.3. FOREIGN GOVERNMENT DELEGATIONS TO INTERNATIONAL CONFERENCES (JAN 2002)

H.4. INSURANCE AND SERVICES

H.5. AIDAR 752.228.3 WORKER’S COMPENSATION INSURANCE (DEFENSE BASE ACT)

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

H.7. AUTHORIZED GEOGRAPHIC CODE

H.8. SALARY SUPPLEMENTS FOR HOST GOVERNMENT (HG) EMPLOYEES

H.9. ADS 302.3.5.13 ACCESS TO USAID FACILITIES AND USAID’S INFORMATION SYSTEM (AUGUST 2013)

H.10. GOVERNMENT FURNISHED FACILITY OR PROPERTY

H.11. CONTRACTOR-MISSION RELATIONSHIPS

H.12. DISCLOSURE OF INFORMATION

H.13. PROHIBITION ON THE PROMOTION OR ADVOCACY OF THE LEGALIZATION OR PRACTICE OF PROSTITUTION OR

SEX TRAFFICKING (ACQUISITION) (APRIL 2010)

H.14. NONDISCRIMINATION (JUNE 2012)

H.15. USAID-FINANCED THIRD-PARTY WEBSITES (AUGUST 2013)

H.16. CONSENT TO SUBCONTRACT

H.17. EXECUTIVE ORDER ON TERRORISM FINANCING (MAR 2002)

H.18. USAID DISABILITY POLICY - ACQUISITION (DECEMBER 2004)

H.19. 752.225-70 SOURCE AND NATIONALITY REQUIREMENTS (FEB 2012)

H.20. TITLE TO AND CARE OF PROPERTY

H.21. 752.7007 PERSONNEL COMPENSATION (JULY 2007)

H.22. ADDITIONAL REQUIREMENTS FOR PERSONNEL COMPENSATION

H.23. EMPLOYMENT OF THIRD COUNTRY NATIONALS (TCNS) AND COOPERATING COUNTRY NATIONALS (CCNS) ... 51

H.24. ORGANIZATIONAL CONFLICT OF INTEREST

H.25. MANAGEMENT OF INFORMATION TECHNOLOGY RESOURCES

H.26. HOMELAND SECURITY PRESIDENTIAL DIRECTIVE-12 (HSPD-12) (SEPTEMBER 2006)

H.27. INTERNATIONAL TRAVEL APPROVAL AND NOTIFICATION REQUIREMENTS AIDAR 752.7032 (APR 2014)

H.28. LANGUAGE REQUIREMENTS

H.29. ENVIRONMENTAL COMPLIANCE AND MANAGEMENT

H.30. PROHIBITION AGAINST DISCRIMINATION (OCT 2011)

H.31. SECURITY CONDITIONS

H.32. ANTI-FRAUD HOTLINE

H.35. PROHIBITION OF ASSISTANCE TO DRUG TRAFFICKERS

SECTION I – CONTRACT CLAUSES

I.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

I.2 52.217-9 -- OPTION TO EXTEND THE TERM OF THE CONTRACT. (MAR 2000)

I.3 52.203-14 DISPLAY OF HOTLINE POSTER(S) (DEC 2007)

I.4 52.203-99 PROHIBITION ON CONTRACTING WITH ENTITIES THAT REQUIRE CERTAIN INTERNAL

CONFIDENTIALITY AGREEMENTS-REPRESENTATION (APR 2015)

I.5 52.222-2 P A Y M E N T FOR OVERTIME PREMIUMS. (JUL 1990)

I.6 52.227-23 - RIGHTS TO PROPOSAL DATA (TECHNICAL) (JUN 1987)

I.7 52.229-8 TAXES - FOREIGN COST-REIMBURSEMENT CONTRACTS. (MAR 1990)

I.8 52.243-7 - NOTIFICATION OF CHANGES (APR 1984)

I.9 52.244-2 - SUBCONTRACTS - ALTERNATE I (JUN 2007) (OCT 2010)

I.10 AIDAR 722.170 - EMPLOYMENT OF THIRD COUNTRY NATIONALS (TCNS) AND COOPERATING COUNTRY

NATIONALS (CCNS)

I.11 AIDAR 731.205-46 TRAVEL COSTS

I.12 AIDAR 752.219 - 8 UTILIZATION OF SMALL BUSINESS CONCERNS AND SMALL DISADVANTAGED BUSINESS

CONCERNS

I.13 AIDAR 752.219-70 USAID MENTOR-PROTÉGÉ PROGRAM (JUL 2007)

I.14 AIDAR 752.225-70 SOURCE AND NATIONALITY REQUIREMENTS (FEB 2012) (CLASS DEVIATION NO. OAA-DEV- 12-01C) 70

I.15 AIDAR 752.227-14 RIGHTS IN DATA—GENERAL (OCT 2007)

I.16 AIDAR 752.228-3 WORKER’S COMPENSATION INSURANCE (DEFENSE BASE ACT)

I.17 AIDAR 752.228-70 MEDICAL EVACUATION (MEDEVAC) SERVICES (JULY 2007)

I.18 AIDAR 752.231-71 SALARY SUPPLEMENTS FOR HOST GOVERNMENT EMPLOYEES (OCT 1998)

I.19 AIDAR 752.245-70 GOVERNMENT PROPERTY—USAID REPORTING REQUIREMENTS

I.20 AIDAR 752.245-71 TITLE TO AND CARE OF PROPERTY (APRIL 1984)

I.21 AIDAR 752.7004 EMERGENCY LOCATOR INFORMATION (JUL 1997)

I.22 AIDAR 752.7007 PERSONNEL COMPENSATION (JULY 2007)

I.23 AIDAR 752.7008 USE OF GOVERNMENT FACILITIES OR PERSONNEL (APR 1984)

I.24 AIDAR 752.7013 CONTRACTOR-MISSION RELATIONSHIPS (OCT 1989)

I.25 AIDAR 752.7025 APPROVALS (APR 1984)

I.26 AIDAR 752.7027 PERSONNEL (DEC 1990)

I.27 AIDAR 752.7028 DIFFERENTIALS AND ALLOWANCES (JULY 1996)

I.28 AIDAR 752.7032 INTERNATIONAL TRAVEL APPROVAL AND NOTIFICATION REQUIREMENTS (APR 2014) (CLASS

DEVIATION OAA-DEV-14-01C)

I.29 AIDAR 752.7101 VOLUNTARY POPULATION PLANNING ACTIVITIES (JUN 2008)

I.30 AIDAR 752.7005, SUBMISSION REQUIREMENTS FOR DEVELOPMENT EXPERIENCE DOCUMENTS (SEP 2013)

(CLASS DEVIATION OAA-DEV-13-01C)

SECTION J - LIST OF ATTACHMENTS

SECTION K - REPRESENTATIONS, CERTIFICATIONS AND OTHER STATEMENTS OF OFFERORS

K.1 NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY REFERENCE

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

K.3 52.222-21 PROHIBITION OF SEGREGATED FACILITIES (FEB 1999)

K.4 INSURANCE - IMMUNITY FROM TORT LIABILITY

K.5 52.204-3 TAXPAYER IDENTIFICATION (OCT 1998)

K.6 52.209-5 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER

RESPONSIBILITY MATTERS (APRIL 2010)

K.7 52.230-1 COST ACCOUNTING STANDARDS NOTICES AND CERTIFICATION (JUNE 2000)

K.8 52.230-7 PROPOSAL DISCLOSURE--COST ACCOUNTING PRACTICE CHANGES (APR 2005)

K.9 COMPLIANCE WITH VETERANS EMPLOYMENT REPORTING REQUIREMENTS

K.10 SIGNATURE

SECTION L—INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS

L.1. 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998)

L.2. NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

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

L.4. GENERAL INSTRUCTIONS TO OFFERORS

L.5. PROCEDURES FOR THE SUBMISSION OF PROPOSALS BY E-MAIL

L.6. INSTRUCTIONS TO OFFERORS – COMPETITIVE ACQUISITION 52.215-1 (JAN 2004)

L.7. SERVICE OF PROTEST 52.233-2 (SEP 2006)

L.8. INSTRUCTIONS FOR THE PREPARATION OF THE TECHNICAL PROPOSAL

L.9. INSTRUCTIONS FOR THE PREPARATION OF THE COST PROPOSAL

L.10. PREPERATION OF THE BRANDING AND MARKING PLAN

SECTION M—EVALUATION FACTORS FOR AWARD

M.1 AWARD WITHOUT DISCUSSIONS

M.2 SOURCE SELECTION

M.3 DETERMINATION OF COMPETITIVE RANGE

M.4 TECHNICAL PROPOSAL EVALUATION FACTORS

M.5 EVALUATION METHODOLOGY

M.6 EVALUATION OF COST PROPOSALS

M.7 CONTRACTING WITH SMALL BUSINESS CONCERNS AND DISADVANTAGED ENTERPRISES

SECTION J – LIST OF ATTACHMENTS

PART I - THE SCHEDULE

SECTION B - SUPPLIES OR SERVICES AND PRICE/COSTS

B.1. PURPOSE

The United States Agency for International Development’s (“USAID” or the “Agency”) mission to the Islamic Republic of Pakistan (“Pakistan,” and, together, “USAID/Pakistan” or the “Mission”) requires technical services to implement Health Initiative for FATA/KP province in Pakistan as described in Section C.

B.2. CONTRACT TYPE

This is a Cost-Plus-Fixed-Fee Completion Type Contract. For the consideration set forth in the contract, the Contractor must provide the deliverables and outputs described in Section C and Section F.

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

(a) The total estimated cost for the performance of the work required for the contract, exclusive of fixed fee, if any, is $[TBD]. The fixed fee, if any, is $[TBD]. The total estimated cost plus fixed fee, if any, is $[TBD]. USAID will not pay the Contractor any sum in excess of the total estimated cost.

(b) The total obligated amount available for reimbursement of allowable costs incurred by the Contractor

(and payment of fixed fee, if any) for performance under the contract is $[TBD]. The Contractor must not exceed the aforesaid obligated amount in accordance with Federal Acquisition Regulation (“FAR”) § 52.232.22, “Limitation of Funds.”

B.4. BUDGET

CLIN DESCRIPTION Year 1 Year 2 Year 3 Year 4 Option Year

Year 5 Option Year

Total

001 Human Resource Development for Health

Fixed Fee (if any) $_____ $_____ $_____ $_____ $_____ $_____ 002 Health Service Delivery $_____ $_____ $_____ $_____ $_____ $_____ Fixed Fee (if any) $_____ $_____ $_____ $_____ $_____ $_____ 003 Technical Assistance for

Department of Health, Government of Khyber Pakhtunkhwa

Fixed Fee (if any) $_____ $_____ $_____ $_____ $_____ $_____

Total Estimated cost Plus Fixed

Fee

(a) The inclusion of any costs in the above budget does not obviate the requirement for prior approval by the Contracting Officer of cost items designated as requiring prior approval by any of the terms and conditions of this contract, including the applicable cost principles (see FAR § 52.216-7, “Allowable Cost and Payment”); nor, does it constitute a determination of allowability by the Contracting Officer of any item of cost, unless specifically stated elsewhere in this contract. Also, the Contractor must not adjust these amounts without a written modification signed by the Contracting Officer. The Contractor must not bill any amounts against this contract in excess of the amounts specified for each line item.

(b) The Contractor agrees to furnish data that the Contracting Officer may request on costs expended or accrued under this contract in support of the budget information provided herein.

(c) The Contracting Officer based the budget in Section B.4 on the Contractor’s [original proposal or the Final Cost Proposal Revision], which the Contracting Officer accepted through award of this contract.

(d) Without the prior written approval of the Contracting Officer, the Contractor must not exceed the total estimated cost set forth in the budget or the total obligated amount, whichever is less.

(e) Without the prior written approval of the Contracting Officer, the Contractor must not exceed each Contract Line Item Number (“CLIN”) total per year or shift funding between CLINs.

B.5. INDIRECT COSTS

[To Be Determined at Award]

(a) Pending establishment of revised provisional or final indirect cost rates, USAID/Pakistan will reimburse allowable indirect costs on the basis of the following negotiated provisional or predetermined rates and the appropriate bases pursuant to the contractor’s current executed Negotiated Indirect Cost Rate Agreement (“NICRA”):

Description Rate Base Type Period

1/ Base of Application:

Type of Rate:

Period:

(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.

B.6. REIMBURSABLE COSTS

(a) The U.S. dollar costs allowable 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,” FAR § 52.232-20, “Limitation of Cost,” and FAR § 52-232-22, “Limitation of Funds,” if applicable, and AIDAR 752.7003, “Documentation for Payment.”

B.7. PAYMENT OF FIXED FEE

(a) USAID/Pakistan will pay a proportion of the contractor’s fixed fee each month pursuant to FAR § 52.216-8, “Fixed Fee,” upon the receipt of an invoice deemed proper by the Office of Financial Management in USAID/Pakistan.

(b) In the event the Contractor does not submit the required deliverables at the conclusion of the period of performance, the Contracting Officer will adjust the fixed fee proportionately to the deliverables accepted. For example, if USAID/Pakistan accepted 85% of the deliverables, then the Contractor remains entitled to 85% of the fixed fee amount; provided, however, that the Contractor satisfactorily performs the terms of the contract.

B.8. CANCELLATION DATES AND CEILING

USAID/Pakistan considers this contract non-severable. Therefore, as a multi-year contract as defined in FAR § 17.103, the contract remains subject to the requirements contained in FAR § 17.106.

However, as a cost-reimbursement contract, USAID/Pakistan will authorize the reimbursement for all allowable costs incurred by the Contractor pursuant to FAR § 52.216-7, “Allowable Costs and Payment.” As a result, the Contractor will not incur any costs that require amortization over the contract’s period of performance in the event that the Contracting Officer cancels the contract pursuant to FAR 52.217-2. Thus, $0 will serve as the cancellation ceiling for each cancellation date.

Accordingly, no requirement to include cancellation dates in the contract exists

[END OF SECTION B]

SECTION C– STATEMENT OF WORK

ACRONYMS

AJK Azad Jammu and Kashmir BEmONC Basic Emergency and Obstetric and Newborn Care CEmONC Comprehensive Emergency Obstetric and Newborn Care COR Contracting Officer’s Representative CMW Community Midwife DfID Department for International Development DOH Departments of Health FATA Federally Administered Tribal Areas GDP Gross Domestic Product GOP Government of Pakistan KFHI KP-FATA Health Initiative KP Khyber Pakhtunkhwa LHW Lady Health Worker MCH Maternal and Child Health MDGs Millennium Development Goals MMR Maternal Mortality Rate MNCH Maternal Newborn and Child Health MNHSRC Ministry of National Health Services Regulation and Coordination MOU Memoranda of Understanding PC-1 Planning Commission Proforma 1 PEPA Pakistan Enhanced Partnership Agreement TBD To Be Decided US United States USAID United States Agency for International Development USG United States Government

C.1 PURPOSE

Through the KP-FATA Health Initiative (KFHI), USAID/Pakistan will sustainably increase the availability of maternal and child (especially newborn) health services in seven districts of the Malakand Division of Khyber Pakhtunkhwa (KP) and Federally Administered Tribal Areas (FATA) to improve the health outcomes of mothers and their children. KFHI will be a three-year contract with two one-year options. By focusing on improvements within the continuum of care, USAID expects to address the key factors of maternal and child mortality. This Activity is an element of the Maternal and Child Health (MCH) Program, which is the main vehicle to achieve USAID’s Health Sector Development Objective 5: Improved maternal and child health outcomes in focus areas, which contributes to “increased stability, democracy and prosperity for the men & women of Pakistan.” The MCH Program supports innovative approaches to strengthen the capacity of Pakistan's public and private healthcare sectors to deliver high-impact services that reduce maternal, newborn, and child mortality and morbidity, as well as improve reproductive health outcomes and increase family planning utilization.

In the Khyber Pakhtunkhwa Province, the Contractor will work in all seven districts of Malakand Division.1 In the FATA, the Contractor will work in six of the seven agencies.2 Given the current military operation in the North Waziristan Agency, USAID does not expect the Contractor to be able to implement activities during the base 3 years.3 If the security situation allows - based on consultation with the FATA Secretariat -the activities may commence in North Waziristan in the option year 1. The Contractor will work in close collaboration with the public sector and will sign two separate MOUs with the Health Departments of the Governments of KP and FATA for the whole project before starting implementation. Similarly, the Contractor will sign two separate MOUs with the Education Departments of the Governments of KP and FATA for Accelerated Education Program described below in section C.4.1.3. The Contractor will draft the MOUs mentioning specific responsibilities of the Health/Education Department and the implementing partner. The draft MOUs will be shared with USAID/Pakistan for clearance before presenting it to the respective Governments of KP and FATA. The cleared MOU will be shared with the host Government (KP and FATA) and if there are any suggested changes, the final version will be submitted to USAID/Pakistan for final clearance.

C.2. BACKGROUND

C.2.1 Country Context

Pakistan has the highest population growth and birth rates in South Asia.4 Adding over 4 million people annually, the population of Pakistan will surpass 300 million by 2050.5 It is the world’s sixth most populous country and is projected to become the fourth most populous by 2050.6 The rapid population growth is overwhelming the government’s ability to provide power, food, jobs, health, and education. Current water supplies, already inadequate in many regions, will fall short of national demand by 2025; the burgeoning poor will be increasingly less resilient to complex disasters. Pakistan’s population growth rate (1.52%)7 will continue to acutely challenge all sectors in the coming decades.

1Chitral, Dir Lower, Dir Upper, Swat, Malakand, Buner, and Shangla districts 2Bajaur, Mohmand, Khyber, Orakzai, Kurram, and South Waziristan 3 USAID supported UNICEF and UNFPA to implement humanitarian health activities related to the conflict and affected populations 4http://www.mapsofworld.com/asia/thematic/countries-by-birth-rate.html 5Report by Population Division of the Department of Economic and Social Affairs of the United Nations 6http://defence.pk/threads/pakistan-to-become-4th-largest-nation-by-population-in-2050.63702/ 7 2013 CIA Work Fact book entry: https://www.cia.gov/library/publications/the-world-factbook/geos/pk.html

In 2010, the Government of Pakistan passed the 18th amendment, which abolished federal social service ministries – devolving responsibility to the four provinces. Enacted quickly, this process exacerbated the already weak capabilities of provincial and district governments and added additional ambiguity around accountability and resource flows for programs that had previously been federally funded and managed (like the Lady Health Worker program, for example). Nonetheless, the fundamental principles of decentralization offered new opportunities to address weaknesses in the health system as part of a strengthened social contract. Over the last five years, there have been differing levels of success in the four provinces:

Balochistan, KP, Sindh, and Punjab. In the case of KP, there has been moderate success. For example, the Integrated Development Strategy (2014-18), which includes health, was developed by the government.

Likewise, the four preventive programs (Maternal, Newborn and Child Health Program, Lady Health Worker Program, Nutrition Program, and Expanded Program on Immunization) funded and managed by the federal government previously, were taken over by the provincial government and an integrated Planning Commission Proforma 1 (PC-1) was approved. Despite these successes, a significant amount of work is still needed.

After the 18th Constitutional Amendment in 2010, health was devolved to the provinces, the federal Ministry of Health was disbanded and the regions of AJK, FATA, and Gilgit-Baltistan fell under the management of the Ministry of Inter-provincial Coordination. In 2013, the GOP re-established several federal ministries, including health with core mandates related to coordination and regulation. Management of the three regions fell to the newly instituted Ministry of National Health Services Regulation and Coordination (MNHSRC).

According to the World Bank statistics, the majority of Pakistanis reside in rural areas with a split of 38 percent urban and 62 percent rural,8 and two-thirds of the total population live below the poverty line of less than $2 per day.9 Rapid population growth has been accompanied by poorly funded health investments by the government (about 1 percent of GDP10); thus, use of government health facilities is low due to health provider absenteeism, poor service quality, informal payments, and poor provider behavior. These public sector failures in providing quality healthcare have resulted in the emergence of unregulated and often grossly inadequate private sector service providers; over 75 percent of Pakistanis now access healthcare through the unregulated private sector.11 Out-of-pocket expenditures are significant for both the urban and rural, and unexpected health expenditure in the family are a major contributor to poverty; all of which set up a vicious cycle that precludes people from seeking needed care and desired services.

Poor health outcomes for women and their children is compounded by gender inequities in Pakistan and social norms that limit women’s mobility and access to health services, education, and employment. In many parts of the country (like FATA and Malakand Division), cultural norms do not permit women and children to travel to health facilities for care, or to receive care from male practitioners – particularly for reproductive health services, pregnancy, and delivery. In addition, access to health services is complicated by long distance, poor quality and availability of staff and services, lack of financial means, and absence of comprehensive outreach services.

Only 26 percent of Pakistani women use modern contraceptives despite the fact that 70 percent report they wish to delay or avoid future pregnancies.12 This high unmet need for family planning results in unintended pregnancies, which directly contribute to high maternal and child morbidity and mortality. Every day, over 1,100 children under the age of five die from largely preventable diseases; two-thirds of these deaths are

8http://data.worldbank.org/indicator/SP.RUR.TOTL.ZS 9http://www.dawn.com/news/1110248 10http://data.worldbank.org/indicator/SH.XPD.PUBL.ZS 11http://www.marxist.com/pakistan-crisis-medical-sector-health-care.htm 12Batool Zahid, Sabahat Hussain, “Reasons for Low Modern Contraceptive Use – Insights from Pakistan and Neighboring Countries,” Population Council, 2012-13; PDHS 2012-13.

within the first month of life. Of those who survive, 44 percent suffer from stunting13, which results in irreversible brain damage, weakened immune systems, and physical impairments after age two. Under-nutrition over generations traps families and communities in a vicious cycle of poor nutrition, poor health, reduced human capital, and poverty.

According to the World Health Organization (WHO), 5.9 million children under the age of five die worldwide.14 Pakistan contributes 423,000 of these deaths. Infant deaths account for approximately two-thirds, and Pakistan has the highest rate of first day deaths of newborn in the world. For children who survive past their first birthday, there is a high disease burden of diarrhea and pneumonia. Similarly, Pakistan’s under-five mortality national average of 86 deaths per 1,000 live births is alarmingly high.15

C.2.2. Key Challenges for Khyber Pakhtunkhwa and FATA

In addition to the specific child and infant health challenges mentioned above, KP and FATA face multiple socio-political problems. While KP has its own population estimated at 22.2 million, it also hosts an additional 3 million Afghan refugees. Its population is young with 72 percent under 30 years of age and 47 percent under 15.16 The average household size at nearly eight people is the highest in Pakistan. Within the KP Province, poverty is highest in the districts of Shangla and Upper Dir, and is also high in Buner, Kohistan and Battagram. In these areas landholding is small, resulting in limited agriculture, and because they are remote, job opportunities are negligible.17 While there has been a recent increase in the number of females attending school, their levels are still lower than boys. Employment rates for women are low, and representation in government and senior decision-making positions is very limited. Most women are economically dependent on male family members, shoulder the majority of household work, and have literacy levels well below the national average.

The territories that form FATA consist of seven agencies: Bajaur, Mohmand, Khyber, Orakzai, Kurram, North Waziristan, and South Waziristan, as well as six smaller zones called Frontier Regions in the districts of Bannu, Dera Ismail Khan, Kohat, LakkiMarwat, Peshawar and Tank. To the north and east, the tribal areas are bound by KP, while on the south lies Balochistan. In the southeast, FATA meets Punjab. The Durand Line, which separates Pakistan from Afghanistan, forms the western border of FATA. FATA is controlled by the Federal Government of Pakistan, where the Governor of KP exercises federal authority on behalf of the President. The Constitution of Pakistan governs FATA through the same rules, which were framed by the British in 1901 as Frontier Crimes Regulations. The Jurisdiction of Supreme Court and High Court of Pakistan do not extend to FATA. The last three decades have seen turmoil and instability in the region, and FATA remains one of the most insular and isolated corners of the country – cut off from the mainstream of Pakistani society. Its people have seen few of the benefits of development activities launched in their own area and have failed to share the progress achieved elsewhere in the country. Increasingly impoverished and marginalized, they have become vulnerable to exploitation at the hands of criminal and extremist elements.

Literacy rate is quite low (measured at 17.42 percent in 1998), and only 43 percent of residents have access to clean drinking water.18 The socioeconomic indicators of FATA show that it is one of the poorest areas of the country.

13 Country Profile, Pakistan, World Health Organization, 2013, http://www.who.int/ 14 Under-Five Mortality, 2015, http://www.who.int/gho/child_health/mortality/mortality_under_five_text/en/ 15 Statistics, http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html 16 National Institute of Population Studies (NIPS) Pakistan, and Macro International Inc. 2008. Pakistan Demographic and Health Survey 2006-07.

17Iftikhar A. Cheema, “A Profile of Poverty in Pakistan,” Center for Research on Poverty Reduction and Income Distribution, Planning Commission, Islamabad: 2005 18http://www.fata.gov.pk/index.php?link=9

As a result, the health indicators of the proposed focus areas for USAID health programming in FATA and KP are poor: the skilled birth attendance is low (48% in KP,19 26% in FATA20) and the majority of health facilities are unable to manage complicated cases of child birth. The situation is further complicated by poor transport options for patients. All these factors have led to very highest maternal mortalities. Maternal Mortality Rate (MMR) in FATA is 380/100,000 live births and MMR in KP is 275/100,000 live births.21

Pakistan Nursing Council has set eligibility criteria for recruitment into the LHWs and CMWs training.

Eighth grade formal education is required for LHWs training, whereas the requirement for CMWs training is tenth grade. Since, the literacy rate is low in both KP and FATA, especially for females; there is likelihood of facing difficulty in finding females for the above-mentioned two training programs.

C.2.3. USAID’s Health Investments

With the passage of the 2009 Enhanced Partnership with Pakistan Law (Kerry-Lugar-Berman), and the subsequent signing of the Pakistan Enhanced Partnership Agreement (PEPA) in September 2010, the USG established a policy framework for increased cooperation with the Government of Pakistan (GOP). The October 2010 U.S.–Pakistan Strategic Dialogue further strengthened the bilateral working relationship by identifying critical sectors for cooperation, and public health emerged as a top priority. To improve the health of Pakistanis, USAID focuses on reproductive, maternal, newborn, and child health as a key element of an overall strategy of stabilization, economic strengthening, and development. Among several development objectives, USAID’s crosscutting programs include support for economic growth, overcoming energy shortfalls to support economic progress, expanding educational opportunities (particularly to females), and promoting peace and stabilization. U.S. assistance also complements Pakistan’s National Poverty Reduction Strategy.

The overall goal of the Mission Strategic Framework of USAID/Pakistan (annexure 1) is “increased stability, democracy and prosperity for the men & women of Pakistan.” The five Development Objectives contribute to the goal, and the KFHI will play a role in the achievement of the third (Increased stability in focus areas) and fifth (Improved maternal and child health outcomes in focus areas) Development Objectives.

Although the MCH Program’s direct service delivery is currently confined to a small geographic area,22 the investments include broader level health systems strengthening work for family planning, immunization, nutrition, WASH, and supply chain. USAID's MCH Program is comprised of six interconnected and mutually reinforcing components, each with one or more activities led by national and internationally renowned public health organizations to implement evidence-based interventions (annexure 2).

C.3 PROJECT OPERATING APPROACH

The purpose of KFHI is to improve the continuum of care from household to hospital for mothers and newborns in focus areas. Health services will be provided through skilled midwives at the community level, supported by Basic Emergency and Obstetric and Newborn Care (BEmONC) and Comprehensive Emergency Obstetric and Newborn (CEmONC) centers at secondary levels. KFHI will include three intervention clusters: 1) human resources for health, 2) service delivery, and 3) technical assistance for the KP Department of Health. Given the geographic focus, the results of this activity will also directly benefit the Mission’s third Development Objective “Increased stability in focus areas” by contributing to the intermediate results of 3.2 (Governance improved) and 3.3 (Essential services delivered).

19PDHS 2012-13,

20MICS FATA 2009

21Source for FATA is the 2009 Multiple Indicator Cluster Survey (MICS); and source for KP is 2006-07 Pakistan Demographic Household Survey (PDHS) 22At this time, USAID’s MCH Program supports service delivery throughout 15 districts of Sindh province

The Contractor will establish a project office in Peshawar. All the key personnel will be based in this office.

In addition, the Contractor should propose the minimum required staff for the project office. The Contractor will setup offices in all the districts and agencies, and will hire the minimum required staff, not more than four persons, for the district/agency office. Space will be rented for Peshawar office; however, the district/agency offices should preferably be established in the District/Agency Health Office (government-owned building). Space can be rented for district/agency office only if the Health Department is unable to accommodate KFHI’s office in the government building due to lack of space. The Contractor should cost rent for all of the district/agency offices; however, expenditure of this line item will be subject to the provision of written statement of the Health Department (District or Provincial/Regional) regarding non-availability of space in the government-owned building, by the Contractor to USAID. The Contractor will work with the provincial/regional health authorities in KP and FATA to ensure that government-owned space is provided in districts/agencies. It should be made part of the MOUs, which the Contractor will sign with the Health Departments of the Governments of KP and FATA.

C.3.1 Cross-cutting Principles

KFHI is intended to complement -- and not replace, compete with, or duplicate -- similar support provided by other development partners in KP and FATA. Establishing parallel systems to the already existing government structures are not desirable, and whenever possible and feasible, host country or existing private/civil society systems are to be used. In addition to being high quality, the Contractor’s key deliverables should be customized and culturally appropriate for the target audiences. The Contractor should pay special attention to both social and normative factors of these areas. The Contractor is expected to work under the existing health strategies of both KP and FATA. The Contractor should ensure that sustainability plans and exit strategies are clearly defined in the initial technical proposal and should expect to work closely with USAID during the final year of implementation to adjust these plans as necessary.

C.4 PROGRAM COMPONENTS

The objectives of KFHI will be accomplished through three key components noted below. Although progress under each component may be tracked separately, they should be seen as inter-connected. This section sets forth the required anticipated activities and specific tasks under each component.

C.4.1 Component I: Human Resource Development for Health The Contractor will provide support to the Governments of KP and FATA to bridge the gap in the human resources for health at the field level. The Contractor will carry out the following three activities under Component I:

C.4.1.1 Recruitment, Training, and Deployment of LHWs

The total number of Lady Health Workers (LHWs) in KP is about 13,200 – with approximately 42 percent population of the province uncovered.23 The proportion of area covered by LHWs in FATA is even less than that of KP. The Contractor will work closely with the Health Departments of KP and FATA, especially with the LHWs programs, to recruit females from the uncovered areas with an 8th grade education or above using the recruitment criteria established by both governments. The Contractor will work with the Governments of KP and FATA to determine barriers in recruitment of qualified candidates. In some areas the Contractor might face difficulty in recruiting females for LHW training. If the barrier is lack of eligible females with the required years of formal education, the Contractor will use the accelerated education program (described in C.4.1.3). If the barrier is unwillingness to send females for training on the part of the family heads, the Contractor will work with the local community, including male and female elders to highlight the necessity and benefits of having local health care providers, especially female. The selected females will be trained by

23Integrated PC-1, Health Department, Government of Khyber Pakhtunkhwa the Contractor for 15 months in the government health facilities on the LHWs Program curriculum. It is necessary to complete the entire process of recruitment and training in complete collaboration with the Health Departments of KP and FATA because after completion of training the LHWs will be handed over to their LHWs Programs for deployment in the field and provision of services in a manner similar to the LHWs trained by the LHWs Program. The Contractor will be responsible for paying the monthly stipend and arranging the training venue and facilitators in consultation with the LHWs Program and health facility in-charge, according to the government regulation. After completion of training, the respective LHWs Programs of KP and FATA will pay the monthly salary. Hence, the Contractor is expected to include it in the MOU with the Governments of KP and FATA that the trained LHWs will become a regular part of the Government LHWs Programs. The Contractor will train 990 LHWs (634 LHWs for KP and 356 LHWs for FATA) during the five years of KFHI. 500 LHWs will be trained in the base three years (320 LHWs for KP and 180 LHWs for FATA).

Tasks to be performed by the Contractor will include, but are not limited to:

• Signing two separate Memoranda of Understanding (MOU) with the Health Departments of the Government of KP and FATA, for collaboration in the recruitment, training, and deployment of LHWs;

• Recruitment of LHWs for training in a phased manner, according to the host government regulations;

• Training of 634 LHWs for KP and 356 LHWs for FATA on the approved LHW curriculum for 15 months in the government health facilities;

• Formally handing over the LHWs, after the completion of training, for deployment in the field to the respective LHWs Programs of the Governments of KP and FATA.

C.4.1.2 Recruitment, Training, and Deployment of CMWs

The Government of KP and FATA trained Community Midwives (CMWs) through the National Maternal Newborn and Child Health (MNCH) Program, and some donor-funded projects; however, there is still need to train more CMWs. The Contractor will work closely with the Health Departments of KP and FATA, especially the MNCH programs, to recruit females from the uncovered areas with 10th grade education or above using the CMW recruitment criteria established by both governments. The Contractor will work with the Governments of KP and FATA to determine barriers in recruitment of qualified candidates. In some areas the Contractor might face difficulty in recruiting females for CMW training. If the reason is lack of eligible females with the required years of formal education, the Contractor will use the accelerated education program (described in C.4.1.3). If the barrier is unwillingness to send females for training on the part of the family heads, the Contractor will work with the local community, including male and female elders to highlight the necessity and benefits of having skilled birth attendants belonging to their own community. Past experience shows that newspaper advertisement usually does not result in getting sufficient application for the training, and engaging community elders is required. Therefore, Contractor has to adopt a proactive approach in finding females for the CMW training. The selected females will be trained for 24 months on the newly approved CMWs curriculum by the Pakistan Nursing Council. The Contractor will train the CMWs in the Midwifery School of the Health Department, Khyber Pakhtunkhwa, managed by the Provincial Health Services Academy and MNCH Program. It is necessary to complete the whole process of recruitment and training in collaboration with the Health Departments of KP and FATA because after completion of training the CMWs will be absorbed by both government MNCH Programs for deployment in the field and provision of services in a manner similar to the CMWs trained by their MNCH Program. The Contractor will be responsible for paying the monthly stipend during the training according to the government regulations;

however, after completion of training the respective MNCH Programs of KP and FATA will pay the monthly salary. Hence, the Contractor is expected to include it in the MOU with the Governments of KP and FATA that the trained CMWs will become a regular part of their MNCH Programs. After Completion of training the Contractor will provide CMW kit to all the trained CMWs. The Contractor will procure and transport the kits to the residence of each CMW. It should be a standard kit according to the criteria of the MNCH Program and formal handing over to the CMW will also be the responsibility of the Contractor. During the five years of KFHI, the Contractor will train 550 CMWs (352 CMWs for KP and 198 CMWs for FATA). 300 CMWs will be trained in the base three years (192 CMWs for KP and 108 CMWs for FATA).

USAID, through Training for Pakistan Project (TFP), trained 189 CMWs (110 for KP and 79 for FATA).

TFP cannot procure equipment; therefore, the Contractor will procure 189 CMW kits for the trained Community Midwives in the first year of KFHI. It should be a standard kit according to the criteria of the MNCH Program. Transportation of the kits to the residence of each CMW and formal handing over will also be the responsibility of the Contractor.

Tasks to be performed by the Contractor will include, but are not limited to:

• Signing two separate MOUs with the Health Departments of the Government of KP and FATA, for collaboration in recruitment, training, and deployment of CMWs;

• Recruitment of CMWs for training in a phased manner, according to the host government policy;

• Training 563 CMWs for KP and 317 CMWs for FATA on the newly approved curriculum for 24 months in the CMW School of the Health Department, Government of Khyber Pakhtunkhwa;

• Formally handing over the trained CMWs, for deployment in the field, to the respective MNCH

Programs of the Governments of KP and FATA.

• Procurement, transportation and handing over of kits to the trained CMWs.

• Procurement, transportation and handing over of 189 kits to the CMWs trained by TFP.

C.4.1.3 Accelerated Education Program

In addition to the challenges of recruiting, deploying, and retaining qualified LHWs and CMWs, many areas of KP and FATA, like Upper Dir and South Waziristan have a shortage of young women with the necessary education to enter pre-service LHW and CMW training. For selection as an LHW and CMW, eighth and tenth grade education is required, respectively. Keeping in view the low female literacy rates in Khyber Pakhtunkhwa and FATA, it is expected that no eligible candidates (having minimum required education) can be found in several locations within this initiative’s intervention area.

However, it is possible to find females with fifth, sixth or seventh grade education. Through a specially designed one-year curriculum, such females can pass the eighth grade to become eligible for recruitment as LHWs. A similar accelerated education program can produce females with tenth grade education for CMW training. The Contractor will design the special one-year curriculum. The Contractor will outsource the task to an individual consultant or consulting firm.

Although this activity will provide eligible candidates for recruitment into the LHW and CMW training programs, the intervention will be carried out in collaboration with the Education Departments of the Governments of KP and FATA. Arrangements will be made by the Contractor with the concerned authorities for utilizing their schools and teaching staff in the afternoon or other suitable times. The Contractor, in coordination with the Health Departments, will identify locations where finding females with minimum required education might be a problem. Females will be recruited from those locations to join the accelerated education program. The Contractor will carry out this activity in the schools of the Government Education Department; however, if government schools are not available or unable to provide this support, nearby private sector schools can be engaged for this purpose. The Contractor should make sure that only those females are selected for the accelerated education programs, which are otherwise eligible (except for the required education level) and interested in recruitment into the LHW/CMW training. Consent of the Education as well as Health Departments of the Governments of Khyber Pakhtunkhwa and FATA is required for this activity. The Contractor will make it part of the MOUs with the Health Departments. In addition, the Contractor will sign two separate MOUs with the Education Departments of the Governments of KP and

FATA. The Contractor will fulfill all these requirements and will train 250 females (160 females for KP and 90 females for FATA) in the initial two years of the project through the accelerated education intervention.24

Tasks to be performed by the Contractor will include, but are not limited to:

• Identification of areas, in collaboration with the LHWs and MNCH Programs of KP and FATA, that lack eligible females (having eighth and tenth grade education) for recruitment into the LHW and CMW training;

• Signing two separate Memoranda of Understanding (MOU) with the Education Departments of the Governments of KP and FATA, for utilizing their schools and teaching staff;

• Signing Memorandum of Understanding (MOU) with the management of the private schools, if required.

• Signing separate Memoranda of Understanding (MOU) with Health Departments of the Governments of KP and FATA, to induct these females into their respective LHWs and MNCH Programs after completion of the relevant health training;

• Designing special curricula for eighth and tenth grade Accelerated Education Program through hiring an individual consultant or consulting firm;

• Signing a bond with the selected females for completing the required minimum education, LHW/CMW training, and subsequent deployment in the field for service provision;

• Providing accelerated education (eighth and tenth grade) to 160 females from KP and 90 females from FATA;

• Recruitment of these females into the LHW/CMW training after the completion of the accelerated education program.

C.4.2 Component II: Health Service Delivery

The Contractor will provide support to the Governments of KP and FATA in improving the health service delivery, especially for mothers and children. The Contractor will carry out the following two activities in Component II:

C.4.2.1 Establishment of BEmONC and CEmONC Centers

While childbirth is a normal physiologic process, all cases do not result in normal deliveries, and proper referral system (including emergency obstetric care) is necessary for these cases. In places like rural/remote KP and FATA, pregnant women do not have access to emergency obstetric care for themselves, nor do they have emergency neonatal care for their newborns. This warrants having 24/7 centers properly equipped to manage complicated cases of delivery around the clock. The Contractor will identify one government run health facility in both KP and FATA for the establishment of CEmONC centers. Health facility will be selected jointly by the Contractor and the respective Health Departments of the Governments of KP and FATA. The health facility should have a large catchment area, like Agency/District Headquarters Hospital.

24150 females will get accelerated education to pass eighth grade, and the remaining 100 will be the target for tenth grade.

The Contractor will make the health facility operational 24/7 for the provision of CEmONC services. Making a government health facility operational round-the-clock usually requires up-gradation in terms of maintenance of physical structure, equipment, supplies, and human resource. The Contractor is expected to carry out a needs assessment exercise for facility up-gradation.