US_PMI_for_States_-_SOL-620-16-000009.pdf

SOL-620-16-000009

U.S. President’s Malaria Initiatives for States

ACRONYMS

AARAD Acquisition and Assistance Review and Approval Document ACTs Artemisin-based Combination Therapies ADS Automated Directive System AIDS Acquired Immune Deficiency Syndrome AL Artemether Lumefantrine ANC Antenatal Care AQ Artesunate Amodiaquine CDC Center for Disease Control and Prevention CDCS Country Development Cooperation Strategy CHWs Community Health Workers c-IPTp Community Intermittent Preventive Treatment for pregnant women COP Chief of Party COR Contracting Officer Representative DEC Development Evaluation Clearing House DfID Department for International Development DHIS District Health Information System DHS Demographic Health Survey DOT Direct Observed Therapy DTET Drug Therapeutic Efficacy and Testing EMMP Environmental Mitigation and Monitoring Plan FANC Focused antenatal care FMoH Federal Ministry of Health GHI Global Health Initiative GoN Government of Nigeria HIV Human immunodeficiency Virus HMIS Health Management Information System HPN Health Population and Nutrition Office HSS Health System Strengthening iCCM integrated community case Management IDIQ Indefinite Delivery Indefinite Quantity IEE Initial Environmental Examination IPRS Implementing Partner Reporting System IPTp Intermittent Preventive Treatment in pregnancy IR Intermediate Result IRS Indoor Residual Spraying ISTp Intermittent Screening and Testing in pregnancy ITNs Insecticide treated Nets LGA Local Government Authority M&E Monitoring and Evaluation MAPS Malaria Action Program for States MCH Maternal and Child Health MDA Mass Drug Administration MEMS Monitoring and Evaluation Management Systems

MEO Mission Environmental Officer MICS Multiple Indicator Cluster Survey MIP Malaria in Pregnancy MIS Malaria Indicator Survey MoH Ministry of Health MOU Memorandum of Understanding NDHS Nigeria Demographic and Health Survey NMEP National Malaria Elimination Program NMSP National Malaria Strategic Plan OAA Office of Acquisition and Assistance OPD Out Patient Department PAD Project Appraisal Document PHC Primary Health Care PMI President’s Malaria Initiative PMP Performance Monitoring Plan PPMV Proprietary Patent Medicine Vendors QA/QC Quality Assurance and Quality Control RDTs Rapid Diagnostic Tests RFP Request for Proposal RHMNCH Reproductive Health, Maternal, Neonatal and Child Health SBCC Social and Behavior Change Communication SMC Seasonal Malaria Chemoprevention SOPs Standard Operating Procedures SP Sulfadoxine-pyrimethamine TB Tuberculosis TSHIP Targeted States High Impact Project TSSP Task Shifting and Sharing Policy USAID United States Agency for International Development USG United States Government WHO World Health Organization WMR World Malaria Report

PART I—THE SCHEDULE

SECTION B – SUPPLIES OR SERVICES AND PRICE/COSTS

B.1 PURPOSE

The purpose of this Contract is to provide services that fall within the Performance Work Statement (PWS) specified in Section C for the U.S. President’s Malaria Initiative for States Indefinite Delivery Indefinite Quantity Contract (IDIQ). USAID Task Order Contracting Officers (TOCOs) will request the work through the issuance of TOs during the ordering period as specified in Section F of the Contract.

B.2 CONTRACT TYPE AND SERVICES

This is a Single Award Indefinite Delivery Indefinite Quantity Contract (IDIQ) utilizing individual TOs to provide technical services. The Government will issue TOs that are Cost-Plus- Fixed-Fee (CPFF) (term or completion), Cost-Plus-Incentive-Fee (CPIF), Cost-Plus-Award-Fee (CPAF) or Firm-Fixed-Price (FFP) or a combination thereof.

B.3 MINIMUM ORDER GUARANTEE

The minimum order guarantee for this Contract is $25,000. USAID/Nigeria is required to order and the contractor is required to furnish the minimum order amount of services. The initial obligation is expected to be applied towards the first TO issued along with the award of the basic Contract.

Following this initial obligation, individual TOs will obligate funds to cover the work required under each TO.

B.4 MAXIMUM CONTRACT CEILING

This is a Single Award IDIQ with an overall ceiling not to exceed $90,000,000.00. The maximum aggregate dollar value of TOs awarded cannot exceed the Contract ceiling.

B.5 FIXED FEE CEILING (Cost-Plus- Fixed-Fee Task Orders Only)

(a) For each cost-reimbursement TO issued under this IDIQ, the TOCO and Contractor agree to negotiate a set dollar amount for fixed fee. In negotiating the fixed dollar amount for fee, the TOCO must consider the policies and factors for establishing fee in FAR 15.404-4 as well as any applicable USAID policy on establishing a fixed fee amount and any additional considerations received to include a Letter of Credit. In no event, however, may the amount of fixed fee in any individual TO exceed (TBD) percent of the task order’s estimated cost, excluding fee.

This fee ceiling is not applicable to Grants under Contracts (GUCs), if any, or other costs that have a separate fee ceiling established in the contract. The fixed fee ceiling applies to the prime contract and all cost reimbursement subcontracts.

Fees for CPIF or CPAF task order types will be negotiated by the TOCO at the time of task order award.

(b) The ceiling on fixed fee does not apply to Firm-Fixed-Price (FFP) TOs.

(c) No fee on fee is authorized. Primes that are represented in Joint Ventures and are also proposed as subcontractors are authorized to propose fixed fee under either the prime Contract or the subcontract, not both.

(d) Fixed Fee Payment. For any TO issued under this Contract, at the time of each payment of allowable costs to the contractor, the USAID paying office ordinarily pays the contractor a percentage of fixed fee that directly corresponds to the percentage of allowable costs being paid.

Two exceptions to paying fixed fee in this manner apply:

(1) If the TOCO determines that this method results in paying a disproportionately higher ratio of fixed fee than the percentage of work that the contractor has completed, then the TOCO may suspend further payment of any fixed fee until the contractor has made sufficient progress to justify further payment, up to the agreed percentage.

(2) In accordance with "Allowable Cost and Payment" (FAR 52.216-7) and "Fixed

Fee" (FAR 52.216-8), the terms and conditions of these clauses apply after total payments of fixed fee reach eighty-five percent (85%) of the total fixed fee.

(e) Separate Fixed Fee Ceiling Applicable To Grants Under Contracts (GUCs)

(1) In no event may the amount of fixed fee (if any) applicable to GUCs in any individual TO exceed TBD percent of the TO GUC cost. -Or-

(2) If a Letter of Credit has been issued to the Contractor for GUC expenditures only, in no event may the amount of fixed fee (if any) applicable to GUCs in any individual TO exceed TBD percent of the TO GUC cost.

B.6 INCENTIVE FEE AND AWARD FEE

(a) For each CPIF TO issued under this IDIQ, the TOCO and Contractor agree to negotiate the target cost, target fee, and fee adjustment formula. The Government also reserves the right to utilize non-monetary incentives.

(b) For each CPAF TO, issued under this IDIQ, the TOCO and Contractor agree to negotiate an estimated cost, base fee, an award fee, a maximum fee (the sum of the base and award fee amounts), and a fee payment plan. Award fee determinations will be made unilaterally by the

CO, in accordance with an approved evaluation plan, and such determinations will not be subject to appeal under the Disputes clause of the contract.

B.7 CONTRACT LINE ITEMS (CLINs)

CLINs will be established based on requirements in the respective TOs.

B.8 LABOR (Only applicable to cost reimbursement type task orders)

(a) Central management costs will be handled through the following method:

Contractors will be authorized to bill USAID directly for IDIQ management costs as specified in a TO to be issued under a separate solicitation.

(b) Unburdened Ceiling Daily Rates (CDR)

(1) The TO rates must not exceed the CDRs set forth in the table in Section B.11 below.

Each CDR for personnel listed below is “unburdened” and must only include salary costs or consulting rates of the individual providing the services.

The CDR for employees must not include the following:

(i) Payroll costs (fringe benefits, FICA, allowances, differentials, etc.);

(ii) Indirect Costs applicable to labor; and,

(iii) Profit or fee, if any.

The CDRs set forth in Section B.11 are fixed for the contract period and is for a productive eight (8) hour day, and apply to all subcontractors set forth in clause 52.244-2 in Section I. If a new subcontractor is proposed for a specific TO on other than a fixed-price basis, the CDRs set forth in Section B.11 below will apply, and the subcontract is subject to consent by the TOCO in accordance with FAR Part 44.

Actual salaries for all personnel will be negotiated under task orders and final approval is provided by the TOCO. The ceiling rates presented below do not constitute approval of final salary rates above the Contractor Salary Threshold (CST) (see ADS 302).

(2) The single unburdened ceiling daily rate for each labor category/group below represents the mid-level and senior level rate in each category/grouping. One unburdened ceiling daily rate for each labor category/grouping is included in the contract to provide more flexibility under task orders. If junior-level personnel are required under task orders, they must be proposed at rates below the unburdened ceiling daily rate.

(c) Minimum Qualifications

In order to perform the PWS set forth in Section C, the Contractor must provide personnel that meet the minimum education and experience requirements set forth below. These minimum qualifications correspond to the labor matrix in Section B.11.

Language fluency, relevant regional experience, and international development experience requirements will be specified in individual task orders.

*Highest degree obtained should be related to work being performed.

** Experience should be related to the work being performed.

***Relevant Work Experience is required for the levels indicated.

**** Applies to Non US academic qualification equivalence.

(d) Subcontractor Rates

The following provides guidance for various subcontracting arrangements:

(1) The Prime subcontracts with an approved subcontractor from the original IDIQ competition.

Education + Experience Requirements OR

Experience Requirements (Substitution of Relevant Work Experience in Lieu of a Degree)

Level Academic Degree*

AND Years of Relevant Work Experience**

Years of Relevant Work Experience***

Junior Level

BS/BA

Less than

BS/BA****

0-4 10

Mid

Ph.D. 4

JD/ABD 5

MS/MA/MB 6

BS/BA 8

Less than

BS/BA**** 10

Senior

Ph.D. 8

JD/ABD 10

MS/MA/MB 12

BS/BA 15

Less than

BS/BA**** 20

The unburdened CDR’s for the prime Contract apply to the subcontractor.

(2) The Prime contracts with a new subcontractor not yet approved

The unburdened CDR’s for the prime Contract apply to the new subcontractor.

(3) Prime subcontracts with a new subcontractor not yet approved and may or may not have a different cost accounting system that only processes fully burdened rates. Further, subcontractor proposes rates that are “above” the prime IDIQ rates.

The Prime may then include in its TO proposal, (i) the fully burdened rate proposed to the Prime by the Subcontractor,(ii) allocation of the Prime’s indirect costs in accordance with established accounting practices, and (iii) a reasonable profit. If the rates proposed to USAID, inclusive of the Prime’s allocable indirect costs and a reasonable profit are above the Prime’s unburdened CDRs , the Prime must disclose the amount of the indirect costs, and the amount of the proposed profit that were added to the Subcontractor’s proposed rates. A reasonable profit will be negotiated by the TOCO for the specific TO. The CDRs of the subcontractor must not exceed the prime’s CDRs in the IDIQ Contract.

B.9 LABOR (UNBURDENED CDR) RATE CHANGES

The labor rates are fixed for all Contract years as described within this Contract; however, the Contractor may submit a proposal reducing the labor rates and/or indirect rates at any time during the life of this Contract. The Government will review these proposals and determine if the revised rates are realistic and in the best interests of the Government. If the rates are accepted, the Government will modify the Contract by incorporating the new rates into the Contract.

B.10 STTA BURDENED RATE

Certain TOs may require Short Term Technical Assistance (STTA); whereby, the Offeror may propose daily (8 hours of productive work) fully burdened rates. No additional fee, overhead, G&A, or other costs may be added to the fully burdened rates.

B.11 LABOR MATRIX

The labor rates below are fixed for the life of the Contract unless amended in accordance with B.9:

Labor Level Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr 6 Yr 7

LABOR CATEGORIES

(UNBURDENED)

Jr/Mid/Snr Daily Rate

Daily Rate

Daily Rate

Daily Rate

Daily Rate

Daily Rate

Daily Rate

TBD

TBD

TBD

LTTA (UNBURDENED)

TBD

TBD

TBD

STTA (FULLY

BURDENED)

TBD

Note 1: The Unburdened Ceiling Daily Rates apply to any task order(s) that are awarded under this contract.

Note 2: The Unburdened Ceiling Daily Rates apply to all labor (the prime contractor, subcontractor, TCNs, CCN’s, and consultant salaries). CCN and TCN labor are also governed by the local compensation plan limitations as further provided in note 3 below.

Note 3: Locally Hired National Personnel or Other Non-U.S. Expatriate Rates : All locally hired national personnel and other non-U.S. expatriates must be paid in accordance with AIDAR 722.170.

Salaries for individual locally-hired personnel and other non-U.S. expatriates under this contract and any resulting subcontract must be in accordance with AIDAR 752.7007, Personnel Compensation (July 2007), and should be based upon a combination of factors including the prevailing compensation paid to personnel performing comparable work in the cooperating country as determined by USAID and consideration of the individual's education, work experience and recent relevant salary history.

Unless otherwise authorized by USAID, the compensation for CCN and TCN labor must not exceed the prevailing compensation paid to personnel performing comparable work in the cooperating country as determined by USAID and must be paid in the currency of the cooperating country.

Note 4: The Unburdened Ceiling Daily Rates above do not apply to Fixed-priced Task Orders.

B.12 INDIRECT COSTS (Applicable to cost reimbursement TOs)

Pending establishment of revised provisional or final indirect cost rates, allowable indirect costs will be reimbursed on the basis of the following negotiated provisional or predetermined rates and the appropriate bases for prime contractors and their subcontractors.

Contractor Fringe Rate

Overhead Rate %

Overhead Ceiling Rate%

G&A Rate %

G&A Ceiling Rate %

PRIME (insert) Type of Rate (insert) Base of Application (insert) Source: (insert) Period: (insert)

SUBCONTRACTOR(S)

(insert)

Type of Rate Base of Application (insert) Source: (insert) Period: (insert)

NOTE: Ceiling Rates only applicable to other than small business contractors.

NOTE: Insert additional indirect rates as needed for all primes and subcontractors in the above table.

NOTE: The un-shaded columns in the indirect cost table are the current approved indirect cost rates for the prime and subcontractor(s).

NOTE: For Fixed-priced Task Orders, the overhead ceilings serve as the basis for negotiation only.

NOTE: Contractors are allowed to recoup indirect costs (OH, G&A, etc.) as other direct costs if it is part of the contractor’s usual accounting procedures, consistent with FAR 31 and the contactor’s NICRA.

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.

Reimbursement for indirect costs shall be at final negotiated rates, but not in excess of ceiling rates specified above.

The Government will not be obligated to pay any additional amount associated with indirect costs above the ceiling rates established in the Contract. This advance understanding shall not change any monetary ceiling, cost limitation, or obligation established in the Contract.

B.13 COST REIMBURSABLE (Applicable to cost reimbursement TOs)

The U.S. dollar costs allowable must be limited to reasonable, allocable, and allowable costs determined in accordance with FAR 52.216-7, Allowable Cost and Payment, and FAR 52.216-8, Fixed Fee, if applicable: AIDAR 752.7003, Documentation for Payment; OMB Circular 1-21, Cost Principles for Educational Institutions and OMB Circular A-122, Cost Principles for Non-profit organizations.

[END OF SECTION B]

SECTION C – PERFORMANCE WORK STATEMENT

C.1 BACKGROUND

Globally, there were 210 million malaria cases and 438,000 malaria deaths reported in 2014.

With a population of over 177 million, Nigeria experiences more deaths due to malaria than any country in the world. The global burden of mortality is dominated by countries in sub-Saharan Africa, with the Democratic Republic of the Congo and Nigeria together accounting for more than 35% of the global total of estimated malaria deaths (World Malaria Report 2015). Malaria is transmitted throughout Nigeria, with 97% of the population at risk. According to the National Malaria Strategic Plan (NMSP) for 2014-2010, malaria accounts for 60% of outpatient visits and 30% of hospitalizations among children under five in Nigeria. (National Malaria Strategic Plan 2014 - 2020).

From the 2013 National Demographic and Health Survey (2013 NDHS) Nigeria has registered improvements in infant and under-five mortality from 201/1000 live births in 2003 to 128/1000 live births in 2013. However, pregnant women and children living in places where malaria is highly prevalent are four times more likely than other adults to get malaria and twice as likely to die of the disease (2007 Multiple Indicator Cluster Survey [MICS]).

The 2010 Nigeria Malaria Indicators Survey (MIS) revealed that malaria parasite prevalence is still high, with an average of 42% among children under-five years of age. Zonal variations range from 27.6% in the south-east to 50.3% in the south-west zone. Parasitemia was higher in rural areas (48%) than in urban areas (22%), and decreased as a mother’s education level improved. The 2015 MIS will provide updated data in first quarter of 2016.

The United States Agency for International Development (USAID) Mission to Nigeria Mission anticipates awarding single award IDIQ Contract with subsequent TOs to a highly qualified Contractor to provide facility and community-based malaria case management and prevention of malaria in public and private sectors in nine or more states of Nigeria. This is a flagship Project for the Nigeria Health Program and the U.S President’s Malaria Initiative (PMI). The award will contribute to the reduction of all cause under-five morbidity and mortality, and maternal mortality ratio with its associated complications. The project contributes to the Mission Development Objective 2 “a healthier population in targeted states.”

C.2 STATEMENT OF NEED

C.2.1 Problem Statement

Malaria is the leading cause of morbidity and mortality in Nigeria, with an estimated 110 million malaria cases annually (NMSP 2014-2020). Malaria related deaths account for up to 11% of maternal mortality, 25% of infant mortality, and 20% of under-five mortality resulting in 300,000 childhood deaths annually (NMSP 2014-2020).

High prevalence of malaria, coupled with poor management of uncomplicated and severe malaria is the major contributing factor to the high malaria morbidity and mortality. The http://apps.who.int/iris/bitstream/10665/200018/1/9789241565158_eng.pdf?ua=1 https://onedrive.live.com/?cid=3302216dfa722042&id=3302216DFA722042%21122&authkey=%21AIoRAq6QYIp_o6M https://onedrive.live.com/?cid=3302216dfa722042&id=3302216DFA722042%21122&authkey=%21AIoRAq6QYIp_o6M development hypothesis for this activity is based on the premise that improved coverage of quality services, especially for the vulnerable population of children under five years and pregnant women, coupled with strengthening health systems for malaria commodities, human resources, quality assurance, and regulations; and improved demand and use of malaria case management and prevention of malaria in pregnancy (MIP) services, will result in low incidence of severe malaria and deaths attributable to malaria.

Poor management of uncomplicated and severe malaria is attributable to low quality of health care resulting from:

(1) Health worker skill gaps, ineffective treatment of malaria as a result of presumptive treatment and irrational use of antimalarial drugs;

(2) Restrictive policies that do not allow task shifting to fill the human resource gaps;

(3) Frequent stock outs of malaria commodities (medicines, diagnostic tools);

(4) Use of substandard medicines (monotherapies, outmoded or counterfeit drugs) due to inadequate systems for monitoring, enforcement, and quality control; and,

(5) Knowledge, attitude, and practice gaps as well as inaccessible services that influence health seeking behaviors.

The Ministry of Health malaria policy requires every fever case to be tested for malaria before treatment. Data obtained from Ministry of Health Management Information System (HMIS) shows that less than 15% of fever cases are tested before treatment with antimalarial drugs (NMSP 2014-2020). A cross-sectional survey conducted in January 2013 in 120 randomly selected primary health care facilities across six states and across the six geopolitical zones of Nigeria showed that of the 129,272 patients that presented with fever, only 40% had a malaria test performed (see Mokuolu OA, Ntadom GN, Ajumobi OO, Adedoyin OT, Roberts AA, Agomo CA, et al. Experiences with implementation of malaria diagnostic testing at primary health care in Nigeria: implementation for scale-up. Abuja (FMOH Technical Report), 2013).

Among the health workers interviewed, about one-third (33%) reported they would prescribe Artemisinin-based Combination Therapies (ACT) for a malaria negative test. According to the NDHS 2013, of the children under-five with fever, only 11% had a malaria test performed on them.

Misperceptions, misinformation, and poor practices are common in Nigeria leading to improper management of fevers and malaria at the household level. Negative behaviors include delayed care-seeking, self-medication, presumptive treatment (treating before testing), non-adherence to treatment regimens, and use of substandard drugs and monotherapies. ACTs are the recommended drugs for the management of uncomplicated malaria. However, use of ACTs at the community level to treat malaria is low. Of the under-five children with fever that were given an antimalarial medication for presumed malaria, only 6% received an ACT (2013 NDHS).

Although use of wrong medications like chloroquine or Sulfadoxine-Pyrimethamine (SP) to treat malaria dropped from 79% in the 2010 MIS to 31% in 2013, the continued use of Chloroquine and other monotherapies is still a challenge for effective case management.

There are inequities in access to quality malaria services especially for disadvantaged populations, low social economic class, and rural communities. Most Nigerians first seek treatment for febrile illnesses from the private sector. The 2010 MIS reported that 57% of those with fever first seek treatment from a chemist or Proprietary Patent Medicine Vendor (PPMV) and only 43% from a government facility.

According to the NMSP (2014-2020) and Integrated Maternal, New Born, and Child Health Strategic Plan (2007), the core interventions for control of malaria in pregnancy are:

(1) Intermittent Preventive Treatment for Pregnant women (IPTp) with (SP) drug;

(2) Use of Insecticide Treated Nets (ITN); and,

(3) Prompt testing and effective treatment of suspect malaria episodes. Scale-up of

IPTp continues to be a challenge in Nigeria because of the low Ante-Natal Clinic (ANC) attendance.

The 2013 DHS found that on average, 61% of pregnant women attended ANC, and utilization varied significantly by region, location, residence (urban/rural), age, and mother’s education.

ANC attendance ranged from 17% in Sokoto in the North West zone to 98% in Osun state in the south west. Rural and urban ANC attendance was 46.5% and 86% respectively. Women with secondary education had 97% ANC attendance compared with 36% for those with no education.

Women over age 20 years reported ANC attendance of 61% and above compared to those below the age of 20 years (48%).

Despite the average ANC attendance of 61%, the proportion of women who received two or more doses of SP during their last pregnancy has remained low at 13% in 2010 and 15% in 2013.

Data from the HMIS shows that pregnant women with fevers are treated before testing for malaria for lack of malaria Rapid Diagnostic Tests (RDTs) in ANC facilities. Non availability of SP drug, poor quality of Focused Antenatal Care (FANC) contributes to low uptake of IPTp.

Inadequate funding, unfavorable policy environment, unstable social environment (cultural, political, economic, gender) and weaknesses in the health system provide the basis for the inadequacies in the delivery of quality services for the management of malaria in Nigeria.

Weaknesses in Nigeria’s public health system include:

• Inadequate, inaccessible, and poor quality services;

• Weak referral systems for complicated and severe malaria;

• Weak and uncoordinated commodity logistics systems;

• Frequent stock out of malaria drugs;

• Weak institutional capacity for supervision and quality assurance; and,

• Weak and unreliable Health Management Information Systems (HMIS), and poor or lack of regulatory enforcement, especially on ban of substandard medicines.

Collectively, these inefficiencies impact on the availability of skilled human resources, allocation of resources, decentralization and delegation of services, enabling policies, quality control, enforcement of regulations, and quality of malaria services.

Success for this project will result in:

• Increased malaria test rates from 30% (2014 HMIS) to 85%; in target states;

• Appropriate malaria treatment, according to the national treatment guidelines, in at least

85% of parasitological confirmed malaria cases in target states;

• Increased the proportion of pregnant women receiving three or more doses of IPTp through Directly Observed Therapy (DOT) with SP or any other WHO approved drugs at ANC or community level through community IPTp (c-IPTp) from 2013 NDHS level of 5.8% by at least 50% above the baseline in each target state; and,

• Increased access to appropriate treatment of malaria, pneumonia and diarrhea by 50% from 2015 levels in selected local government authorities through Integrated Community Case Management (iCCM) approach.

C.2.2 Alignment with USAID Goals, HPN Strategic Framework, NMEP and PMI Strategic Plans

The goal of the USAID/Nigeria CDCS is to “reduce extreme poverty in a more stable, democratic Nigeria” (Figure 1). By reducing the malaria burden, this activity will contribute to the reduction of extreme poverty and the achievement of the Health, Population, and Nutrition (HPN) development goal of “a healthier population in targeted states” (Figure 1). This activity will contribute to HPN Intermediate Results (IR) “utilization of quality health services in target areas and population groups increased” by: 1) Strengthening the governance of health systems (Sub-IR 1) and 2) Improving access to quality services (Sub-IR 3).

Figure 1: HPN and HIV/AIDS Results Framework

The National Malaria Elimination Strategy

The Vision of the Government of Nigeria (GoN) National Malaria Elimination Programme (NMEP) is to make Nigeria a malaria free country. This activity is within the GoN malaria policy (revised 2014) and, will contribute to the new NMEP 2014-2020 National Malaria Strategic Plan (NMSP) by providing two core malaria interventions of malaria case management and prevention of malaria in pregnancy. This activity will also address the NMEP NMSP (2014- 2020) cross cutting areas of health system strengthening and monitoring and evaluation.

Additional information can be accessed at National Malaria Strategic Plan 2014 - 2020.

PMI Strategy

This is well aligned to the PMI strategic plan (2015-2020) and, contributes to PMI 2020 goal of:

(1) Reducing malaria mortality by one-third from 2015 levels; and

(2) Reducing malaria morbidity by 40% from 2015 levels. It contributes directly to

PMI strategic approach of “achieving and sustaining scale-up of proven interventions” and “building capacity of health systems towards full country ownership.”

https://rsprqg-dm2305.files.1drv.com/y3m_7iYSuB6FbGMseC01bXbBokSHQPTNRWdOCBpX8aEsIjbl7JT8XqDXrHezVA7JH3bb9ml-SxbmMKvH2lihOK_Q9_0G33G_ZgB6aZTCkDbmAg/National%20Malaria%20Strategic%20Plan2020.pdf?psid=1

This activity subscribes to PMI core principles by: fostering host country ownership and sustainability through working with in the NMEP and State malaria control strategic plans;

investing in health system strengthening; prioritizing high risk populations of children, pregnant women, and populations living in insecure and poor areas; strengthening malaria surveillance, monitoring and evaluation; strengthening coordination with other malaria stakeholders;

innovating and putting to scale proven interventions; ensuring quality of malaria commodities and services; integrating with other health, HIV/AIDS and other disease entities, especially in the areas of health system strengthening, logistics, and capacity building; and expanding and leveraging the private sector to deliver community-based malaria case management and prevention of malaria in pregnancy interventions. Additional information can be accessed at President's Malaria Initiative Strategy 2015-2020.

C.3 PERFORMANCE OBJECTIVES

The U.S. President's Malaria Initiative for States will contribute to the NMEP vision of having “a malaria free Nigeria” and, PMI 2015-2020 goal of reducing malaria-associated mortality by reducing the incidence of severe malaria and associated complications. The goal of this project is to contribute to the reduction of all cause under-five and maternal mortality by delivering quality services for management of malaria and its complications and, prevention of malaria during pregnancy.

The four main objectives are:

(1) Increase malaria test rates from 30% (2014 HMIS) to 85%;

(2) Provide appropriate malaria treatment, according to the national treatment guidelines, in at least 85% of parasitological confirmed malaria cases;

(3) Increase the number of pregnant women receiving three or more doses of IPTp through Directly Observed Therapy (DOT) with SP or any other WHO approved drugs at ANC or community level through community IPTp (c-IPTp) from 2013 NDHS level of 5.8% to at least 80%; and,

(4) Increase access to appropriate treatment of malaria, pneumonia and diarrhea by 50% from 2015 levels in selected local government authorities through integrated community case management (iCCM) approach.

C.4 CORE INTERVENTIONS

The U.S. President’s Malaria Initiative for States will focus on four Core interventions:

(1) Malaria case management, including malaria diagnosis and treatment for uncomplicated and severe malaria, and iCCM;

(2) Prevention of MIP, including community IPTp (c-IPTp);

(3) National and state health system strengthening; and,

(4) Monitoring and evaluation, including malaria surveillance, HMIS, and operational research.

http://pmi.gov/docs/default-source/default-document-library/pmi-reports/pmi_strategy_2015-2020.pdf?sfvrsn=22

C.4.1 Malaria Case Management

(1) Malaria Diagnosis

The NMEP policy requires every fever case to be tested for malaria before treatment. NMEP, with partners, have scaled up this policy to all health facilities in the country. However, adherence to the policy and to the test results is still low. Clinical management of malaria and irrational use of ACTs is common, in both public and private health facilities. Health workers lack the knowledge and skills for differential diagnosis for the malaria negative results.

Parasitological testing for malaria is limited to the laboratories with few laboratory technicians.

Nigeria is implementing a universal campaign for ITNs. Many states have benefited from mass ITN distribution over the last three years. Net access has gone up and net use is improving. With scale up of ITN intervention, the malaria disease burden is expected to go down. The fevers attributable to malaria are also expected to go down. This makes parasitological confirmation of malaria very important for Nigeria.

Currently, PMI supports improving malaria diagnosis using malaria Rapid Diagnostic Tests (RDTs) and microscopy in the eleven PMI focus states. Microscopy is mainly positioned in hospitals and a few Primary Health Care (PHC) health facilities. PMI support includes: training of health workers in malaria microscopy and RDTs; procurement of RDTs, microscopes, reagents, and supplies; development of standard operating procedures; and quality assurance for the blood slides. The quality assurance and quality control system for RDTs is yet to be set up.

In 2012, PMI, with other partners supported the NMEP to revise malaria diagnostic and treatment guidelines to make malaria testing for every fever case the norm for malaria case management. These guidelines apply to both the public and private sector.

In 2014, the Nigeria Federal Ministry of Health passed a Task Shifting and Sharing Policy (TSSP) that will improve the management of malaria in the community. The TSSP policy will improve access to health services. This policy allows Community Health Workers (CHWs), including PPMVs, to conduct malaria testing in the community, using RDTs. The policies provide an opportunity for PMI to scale up iCCM and malaria testing through PPMV and Community Health Workers (CHWs). Proper management of malaria in the community will prevent progression of uncomplicated malaria to severity, and death.

This malaria intervention will support the achievement of the following; but not limited to, results:

• Improved testing rate for malaria in fever cases; and,

• Functional Quality Assurance and Quality Control (QA/QC) systems for malaria microscopy and RDTs.

(2) Malaria Treatment

The NMEP policy, requiring confirmatory parasitological diagnosis before treatment, was a big step towards improving the management of malaria in Nigeria. However, because of low health worker adherence to this policy and to the test results, low compliance to the malaria test results, and low community knowledge about this policy, syndromic management of malaria and irrational use of ACTs is prevalent in health facilities. Use of substandard medicines (monotherapies, counterfeit drugs) is happening in especially the private sector, including Proprietary and Patent Medicine Vendors (PPMVs). The systems for monitoring, enforcement, and quality control of medicines are inadequate. Knowledge, attitude, and practice gaps in the proper management of febrile illness at household and community levels result in seeking for health care.

The National Guideline on Diagnostic and Treatment of Malaria in Nigeria recommends ACTs as the first line drugs for treatment of uncomplicated malaria. The two first line ACTs for treatment of uncomplicated malaria are: Artemether Lumefantrine (AL) and artesunate- Amodiaquine (AQ). The recommended drug for the treatment of severe malaria is injectable artesunate (or quinine, if injectable artesunate is not available). The regimen for management of malaria for pregnant women is quinine in the first semester, and ACTs in the second and third trimesters.

To improve health seeking behavior and effective management of malaria, pneumonia, and diarrhea at the community level, the FMoH adopted the iCCM strategy for the management of these three diseases. The iCCM program includes testing all fevers with a malaria test, using ACT to treat malaria, use of amoxicillin to treat pneumonia, and oral rehydration solution and zinc for diarrhea at the community level. However, policy restrictions and opposition from professional bodies to allow unprofessional workers to handle prescription-only medicines restricted the scale up of iCCM and community-based management of malaria. A number of partners have piloted iCCM and Malaria diagnosis and treatment through PPMVs with good results. In August 2014, with enough data and evidence, the FMoH passed a Task Shifting and Sharing Policy for Essential Health Care Services in Nigeria (2014), allowing PPMVs to handle RDTs. The policy provides an opportunity for Nigeria to scale up iCCM and home based management of malaria.

The NMEP strategic plan (2014-2010) also recommends use of Seasonal Malaria Chemoprevention (SMC) for children under the age of five years that live in areas that experience seasonal but high malaria transmission. NMEP strategy recommends SMC in nine states in Sahel region—Sokoto, Kebbi, Zamfara, Bauchi, Katsina, Kano, Jigawa, Yobe, Borno.

The first four are currently PMI focus states. To date, PMI/Nigeria has not supported SMC but, DfID has supported SMC in Katsina, with good results.

Currently, PMI support for malaria treatment includes: training of health workers in the management of uncomplicated and severe malaria; procurement of ACTs and injection artesunate; development of job aids for malaria case management; technical assistance for revision of treatment guidelines and strategic documents; and mentoring and supportive supervision of health facilities; and BCC for early seeking behavior and proper treatment. In

2014/2015, PMI supported the piloting of iCCM in Bauchi and Ebonyi, using PPMVs and CHWs.

These malaria interventions will support the achievement of the following but not limited to, results:

States and Facility level

• Improved health seeking for treatment of fever in the community;

• Reduced presumptive treatment for malaria;

• Reduced irrational use of first line antimalarial drugs; and,

• Reduced use of monotherapies for treatment of malaria.

Community Level

• Developed Systems for linking community based malaria and iCCM interventions to the health facilities; and,

• Established Community-owned and sustainable motivation schemes for the CHWs.

C.4.2 Prevention of Malaria In Pregnancy

According to the NMSP (2014-2020), the core interventions for prevention of malaria in pregnancy are: 1) IPTp with SP drugs 2) use of ITNs; and, 3) prompt testing and effective treatment of suspect malaria episodes.

NMEP adopted the new IPTp policy of providing IPTp as Directly Observed Therapy (DOT) at every ANC visit after the first trimester, with four weeks between doses. However, NMEP and partners are yet to roll out the new IPTp policy.

Scale-up of IPTp continues to be a challenge in Nigeria because of the low ANC attendance. The average ANC attendance for at least one visit is 61%, with a wide variation between states, and between urban and rural populations. Despite the average ANC attendance of 61%, the proportion of women who received two or more doses of SP during their last pregnancy is low at 15% (NDHS 2013). Stock out of SP or non-availability of SP at ANC clinics, lack of potable water for DOT, low quality Focused Antenatal Care (FANC), and lack of knowledge on IPTp DOT and the new IPTp policy contribute to the low coverage of IPTp.

Testing for malaria and appropriate treatment of pregnant women is low. Midwives do not know how to conduct RDT techniques and RDTs are not provided at ANC clinics.

NMEP has developed a strategy for continuous distribution of ITNs that includes providing an ITN at the first ANC visit and to infants during measles vaccination. NMEP and partners, including PMI, have rolled out this program in all states, and to most health facilities with ANC services. However, it is only states and health facilities receiving PMI and other donor support that are implementing ITN continuous distribution.

PMI/Nigeria is supporting NMEP to implement all the three MIP interventions—IPTp, ITNs, and malaria testing and treatment for pregnant women. The support includes: procurement of MIP commodities—SP, malaria diagnostic equipment, and ITNs; training of health workers in MIP and FANC; issuing ITNs at ANC visits; improving recording of IPTp. However, the support has fallen short of enabling health facilities to implement IPTp DOT, and rolling out the new IPT policy. The Federal Ministry of Health task shifting policy will facilitate PMI to implement c- IPTp in states with low coverage of facility-based ANC.

This mechanism may support the achievement of the following but not limited to, results:

• Improved quality and ANC attendance;

• Increased implementation of IPTp DOT at ANC; and,

• Improved IPTp2+ Coverage.

C.4.3 Health System Strengthening

Inadequate funding, unfavorable policy environment, unstable social environment (cultural, political, economic, gender), poor governance, lack of accountability, and lack of ownership are some of the factors that affect the health service delivery system and, sustainability of malaria control interventions in Nigeria. Health system gaps include: inadequate skilled personnel, poor quality services; weak referral systems for severe malaria; weak and uncoordinated commodity logistics systems leading to frequent stock-out of malaria commodities; weak institutional capacity for supervision and quality assurance; and poor or lack of regulatory enforcement, especially on ban of substandard medicines.

Strengthening host government health systems is a core PMI principle and a main strategy for the NMEP (2014-2020). Currently, PMI and USAID/Nigeria are supporting the strengthening of an integrated logistics system, the strengthening of NMEP leadership capacity for all malaria control interventions; and improving the skills of the service providers. PMI supports NMEP and the states to develop the annual operational plans with a budget line for malaria.

This mechanism may support the achievement of the following but not limited to, results:

• Improved planning, implementation, and coordination of malaria activities at state and national levels;

• Functional NMEP and state malaria coordination processes and activities; and,

• Improved domestic financing for malaria.

C.4.4 Monitoring and Evaluation

Monitoring and Evaluation is one of the weakest areas for health service delivery in Nigeria.

NMEP has a Monitoring and Evaluation plan (2014-2020) that provides a framework for monitoring and evaluating malaria control interventions in Nigeria. The M&E strategic plan recommends use of routine health management information system (HMIS), sentinel surveillance, special surveys, and population-based and facility-based national surveys to monitor performance, outcome, and impact of malaria control interventions.

All states and public health facilities are implementing a national HMIS. States are also implementing the second version of the District Health Management Information System (DHIS2) that transmits electronic data from the local government authorities to state and national level. The HMIS is manual from the health facilities to the local government level. Through the DHIS2 platform, the system becomes electronic from the local government authority level onwards (state and national level.)

All public health facilities in Nigeria are implementing the HMIS. However, the reliability and validity of data generated by the routine HMIS is questionable. The reporting rate for 2014 was 59%. Data generated through the routine HMIS is often incomplete, and has data quality gaps arising from:

• Improper recording in the source documents like the Out-patient department (OPD) register, ANC register, and the laboratory register; and,

• Improper transfer of information from the source documents to the summary forms. Data analysis, interpretation, use, storage, and display contribute to the low use of data generated through the routine HMIS.

PMI supported the NMEP to develop the National Monitoring and Evaluation plan (2014-2020).

Currently, PMI is supporting the implementation of HMIS in the PMI focus states. PMI is also supporting states to hold bi-monthly meetings to discuss data quality issues and, develop strategies to improve data quality. PMI supports the M&E technical working group that coordinates all M&E efforts, including the national and special surveys. PMI support the national population surveys line the DHS and MIS and, the health facility-based rapid impact assessment.

The U.S. President's Malaria Initiative for States will provide comprehensive technical assistance to improve the management of uncomplicated and severe malaria and with its complications as well as prevention of malaria in pregnant women. Individual TOs will address malaria prevention options singly or in any combination of states or sets of interventions. The specific results required under this mechanism will be determined by individual TOs and are likely to be diverse. Specific TOs are expected to address both targeted policy / institutional capacity building interventions addressing sound malaria case management, malaria in pregnancy, health system strengthening, monitoring and evaluation, including malaria epidemiological surveillance, HMIS, Drug therapeutic efficacy monitoring, and operational research.

This mechanism may support the achievement of results including but not limited to, results:

• Improved reporting, completeness, and timelines for HMIS;

• Improved data quality;

• Improved use of data for decision making;

• Established Sensitivity pattern for ACTs; and,

• Established process for operational research, including testing new interventions.

C.5 PERFORMANCE ASSESSMENT

USAID will visit all sites where the Contractor will be working, including but not limited to, offices, communities and field sites for monitoring or other purposes. USAID will use core and non-core indicators to monitor Contractor performance. The contractor shall develop and include a draft M&E plan in the proposal.

C.5.1 Outcome Indicators

USAID will use core malaria outcome indicators and targets below to measure the objectives under Section C. 3. “Objectives”. USAID will also use other non-core malaria output indicators to measure Contractor performance, though these indicators will not count towards the award fee. The Contractor must include all the indicators (core and non-core) in the award M&E plan.

The Contractor will report on the non-core malaria outcome indicators on a quarterly basis.

Where possible, data will be disaggregated by age, sex, service delivery level (health facility, community), category (pubic, private), and state.

Malaria Outcome Indicators

Indicator Baseline Target

Year 1 Target Year 2

Target Year 3

Target Year 4

Target Year 5 Coverage Data source

1. The proportion of under five children with fever tested for malaria—RDT/or microscopy).

12.6% NMIS

2015 20% 40% 60% 80% 80%

2. Proportion of sick children who received appropriate treatment according to protocol for:

a. Malaria 35.4% NMIS 2015 40% 60% 70% 80% 90%

b. Diarrhea 38.1% NDHS 2013 40% 50% 60% 70% 80%

c. Pneumonia 36.5% NDHS 2013 40% 50% 60% 65% 70%

3. The proportion of pregnant women given two or more doses of IPTp as DOT during ANC visits

35% NMIS

2015 40% 50% 60% 70% 80%

4. Dropout rate between first and third doses of IPT (IPT1-

IPT3)

27.6% NMIS

2015 20% 15% 10% 5% 5%

C.5.2 Other Indicators

USAID will use the following additional indicators to monitor the performance of the Contractor.

Performance Indicator *Baseline Target

Coverage Data source

Year

Year

Year

Year

Year

1. Malaria Test Rates at Health Facilities and Community (proportion of under five children with fever tested for malaria—RDT/or microscopy)

2. Malaria positivity rate (proportion of persons testing positive with a parasitological test (RDT and/or microscopy)

3. The proportion of children under five with confirmatory test for malaria treated with ACTs, in accordance with the national treatment guidelines

4. Number of health workers/pers ons trained in:

Malaria diagnosis

Malaria treatment

Prevention of

MIP

HMIS

5. Proportion of targeted health workers/pers ons trained in

Malaria diagnosis

Malaria treatment

Prevention of

MIP

HMIS

6. Proportion of children with severe malaria correctly treated, according to the standard

Performance Indicator *Baseline Target

Coverage Data source

Year

Year

Year

Year

Year

7. Proportion of pregnant women with malaria that receive appropriate and timely treatment according to the national

8. Number of PMI focus states implementing integrated community case management (iCCM).

9. HMIS

Reporting Rate 59% DHIS2 65 75 85 95 100 Timeliness Completeness

10. Proportion of State host funds budgeted for malaria activities

11. Proportion of malaria budget, disbursed for malaria activities

C. 5.3 Monitoring and Evaluation Plan

The M&E plan will provide a basis to track progress against the indicators and targets. The Contractor must include assumptions in the M&E plan that the Contracting Officer and PMI will use to assess progress.

The COR will conduct periodic performance reviews to monitor the progress and achievement of indicator targets and/or completion of major tasks under this Contract. USAID will assess the Contractor’s progress in implementation of its work plan and success in meeting benchmarks, as defined in the Activity M&E Plan with performance milestones. The information provided and exchanged through quarterly progress reviews will form the basis for assessing and reporting on Contractor performance.

USAID and PMI will use various monitoring and evaluation forums to monitor progress and implementation challenges. They include monthly IDIQ COR meetings, the bi-monthly PMI implementing partner meetings, NMEP Technical Working Groups, and State monitoring and evaluation meetings. The Ministry of Health HMIS and the malaria epidemiological monitoring sites will generate data for outcome indicators and trend analysis. USAID/Nigeria and PMI will conduct site visits to assess progress, address challenges, and identify any data quality gaps.

Where…