SOL-687-13-000001_PHC_SOW_for_comments.docx

SECTION C – DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

Acronyms

C.1 OBJECTIVE

The purpose of the Primary Health Care (PHC) project is to: “increase community based primary health care service uptake and the adoption of healthy behaviors.” This will improve the health status of the Malagasy people, which will contribute towards the achievement of the maternal and child health Millennium Development Goals (MGDs). The project will build on previous and current successes in integrated community-based service delivery to promote optimal health behaviors and quality services. It will also embrace USAID Forward procurement reforms by enhancing local ownership through capacity building.

Taking into account lessons learned and best practices from USAID/Madagascar’s integrated community health projects and findings from various assessments, the following are the Sub-Purposes that will support the achievement of the above purpose:

Sub-Purpose 1: To sustainably develop systems, capacity, and ownership of local partners

Sub-Purpose 2: To increase availability of and access to primary health care services in project target communes

Sub-Purpose 3: To improve the quality of community-level primary health care services

Sub-Purpose 4: To increase adoption of healthy behaviors and practices

In compliance with USAID guidance, the project will be managed and implemented and results achieved through the four stated sub-purposes following the logical framework (see Annex B). In addition, USAID/Madagascar has identified three technical areas for project focus:

· Family Planning and Reproductive Health

· Maternal, Newborn, and Child Health

· Malaria Note that the PHC Project does not include activities in the area of HIV/AIDS.

USAID will support achievement of selected activities under these program elements through a contract. Additionally, USAID/Madagascar and USAID/Washington support will be provided through other mechanisms that support this solicitation and are critical to the success of the Project, but are not the responsibility of the Contractor.

The sub-purposes, described more fully in the remainder of the Statement of Work, outline the approaches and results necessary to successfully implement the PHC Project. The PHC Project is expected to build on and further increase the results achieved under Santénet2, making a major contribution to the provision of primary health care services in Madagascar. Rapid start-up of the PHC Project is critical to ensure that community-based services currently supported by Santénet2 continue without disruption (exempting changes in geographic areas). Santénet2 ends on July 24, 2013.

C.2. BACKGROUND AND CONTEXT FOR USAID ASSISTANCE

A. Country Context

Madagascar is one of the poorest countries in the world, with an economic climate that continues to deteriorate. In 2010, the proportion of Malagasies living below the poverty line of $1 per day reached 76.5 percent, an increase from 68.7 percent in 2005 (INSTAT, 2010). The last Demographic and Health Survey (DHS 2008/9), undertaken immediately prior to the current political and economic crisis, showed positive trends in some health areas over the previous survey (2003/4). Madagascar was making progress toward the achievement of the fourth Millennium Development Goal (MDG) on child health, with under-five mortality dropping from 92/1000 to 72/1000 between 2003/4 and 2008/9 (DHS). The percentage of fully immunized children doubled, and infant mortality decreased from 59/1000 to 48/1000. During the same period, use of modern contraception rose from 18 percent to 29 percent (DHS). Despite those successes, maternal mortality and nutrition indicators have stagnated over the past decade. Maternal mortality is 498/100,000, well above the MDG target of 149/100,000. Half of children under five years of age are stunted, indicating chronic malnourishment in this group (DHS, 2008/9). In addition, more than 60 percent of the population does not have access to safe drinking water or improved sanitation facilities (DHS, 2008/9).

Access to quality health services is a major challenge in Madagascar, where over 80 percent of the population live in difficult to reach, rural locations, and 60 percent of those needing care live more than five kilometers from the nearest health facility (World Bank, 2010). Community Health Volunteer (CHV) networks, viewed by the Government of Madagascar (GOM), health development partners, and the international public health community as one of the most important means to reach the predominantly rural population with life-saving primary health care services, are rapidly expanding.[footnoteRef:2],[footnoteRef:3] [2: Haines A. et.al, Achieving child survival goals: potential contribution of community health workers. The Lancet; DOI: 10:.1016/SO140-6736(07) 60325-0, March 2007] [3: Black R. Community Health Workers: Key Agents for Reducing Child Mortality, The Johns Hopkins School of Public Health, 2002]

The national health system includes the public and private sectors, non-governmental organizations (NGOs) and community-based actors. The public sector health delivery system accounts for more than 30 percent of individuals’ first contact with healthcare in urban areas and for more than 70 percent in rural areas (World Bank, 2010). While Madagascar has a higher density of physicians than many other African countries (2.91 per 10,000 population), there is a shortage of nurses and midwives, with a current ratio of 3.16 per 10,000 people (World Bank, 2010). In addition, the unequal geographic distribution of health workers between the rural and urban areas leaves a significant proportion of facilities unable to provide the full range of basic services in rural areas. Further exacerbating this trend, nearly 50 percent of public sector staff is expected to retire in less than ten years (World Bank, 2010). Health sector financing has been marked by poor budget execution, insufficient allocations for the non-salary recurrent budget and low use of the equity fund designed to improve access for the most vulnerable people. Until early 2009, the GOM and its health sector partners were working together to address the most pressing priorities, guided by shared goals articulated in the Madagascar Action Plan 2007-2012 and the National Health Sector Development Plan (Plan de Développement Secteur Santé) 2007-2011. There was a multi-donor effort to integrate vertical supply chains and improve commodity forecasting, ordering, and delivery. Budgetary allowances to the Ministry of Health (MOPH) were increasing. The National Community Health Policy (NCHP) was developed to promote and coordinate community health activities. Safe motherhood was a top priority. Delivery services, including cesarean sections, had just been made free of charge and a national program to expand access to emergency and basic obstetric and newborn care was planned for implementation. A discussion had begun on developing a national package of basic services. The GOM was funding its Expanded Program on Immunization (EPI) for vaccine purchases. Strong national leadership for family planning supported innovative approaches, such as provision of the injectable contraceptive Depo-Provera (DMPA) by Community Health Volunteers. Donor-government relations were productive and an International Health Partnership+ compact was being developed. In January 2009, political tensions erupted and led to an extra-constitutional transfer of power and the subsequent establishment of an interim de facto government, not elected by the populous and not recognized by the international community. At that time, the United States Government (USG) established a policy of restricting aid to Madagascar to humanitarian assistance only and suspending all technical, material, and financial support to the GOM, which included the suspension of USAID support to the public sector. Under the current restrictions, USAID/Madagascar provides support in the health sector through the private sector and NGOs. USAID/Madagascar operates under a humanitarian mandate with the goal of saving lives, alleviating suffering, maintaining human dignity, and targeting the most vulnerable populations in the country. Humanitarian assistance provided through the HPN portfolio is exclusively focused on a variety of community-level, civil society, and private sector interventions.

The ongoing political and economic crisis has the potential to reverse over a decade of progress in improving the health of the population. The public health service delivery system is increasingly under threat with dwindling supply of basic services and vaccines, and increased fragmentation of scarce donor resources through parallel service delivery systems. SALAMA, the national health commodities supply system, experiences supply disruptions, which has an impact on key health indicators, such as immunization coverage. Between 2008 and 2010-11: the GOM reduced the budget for operational costs to health centers by 30 percent; the prescription satisfaction rate, a key indicator for drug availability, declined sharply from 69 percent to 58.9 percent at facility level; the utilization rate of Basic Health Centers (CSB) decreased by 20 percent; and prenatal consultations rate in CSBs went from 74 percent to 62 percent. The lack of human and financial resources has caused the closure of 339 primary health care facilities out of 2,467; the situation seems to be worsening as 151 of these closings occurred in the past year.

In December 2011, the Ministry of Public Health (MOPH) reported alarming drop-offs in Malagasy women seeking health center services for births (from 33.5 percent in 2008 to 21 percent in 2011) and disconcerting increases in hospital reports of maternal mortality (831/100,000 in 2010 to 1,157/100,000 in 2011). These statistics suggest that women are not receiving public health services or are delaying care-seeking for pregnancy complications until it is too late; this may be attributable to declining confidence in public sector services, which is likely compounded by the ongoing economic crisis. With the 2012 national health budget being cut in half from 2011, the situation is dire and worsening.

B. Government of Madagascar National Health Strategy

Although USAID/Madagascar is operating under restrictions which prohibit the provision of support to the GOM, the USG is nevertheless aligning harmonizing its humanitarian assistance, to the degree possible, with national goals and priorities. The USG was heavily involved, along with other donors, in shaping the Health Sector Development Plan (2007-2011) and was fully engaged in the annual progress review process until 2009.

The main goal of the Health Sector Development Plan (2007-2011) is to reduce morbidity and mortality of the population. Intermediate objectives are to:

· Strengthen the national health system

· Improve maternal and child survival (including through family planning)

· Strengthen the fight against illnesses emanating from environmental causes

· Increase health protection and the promotion of healthy behaviors

Given the continued uncertainty of both donor and GOM funding in the sector, the Ministry of Public Health (MOPH) developed an interim plan for 2012-2013 that focuses on available resources and priorities, given donor and GOM funding levels and restrictions. A full strategic plan is expected to be developed for 2014-2018. As part of the coordination allowed under current restrictions, USAID continues to share information on program activities and anticipated funding with the MOPH.

C. Government of Madagascar Youth Action Plan

The Ministry of Youth recently established a National Inter-ministerial Committee on Youth to coordinate activities for youth development and health as well as advocate for recognition of youth rights. The National Committee is in the process of developing a national plan of action for youth that is human rights based, promotes equity and results-based management, and reflects the reality and integrated needs of youth, including health and family planning. Six regional committees have also been established that will adapt the national plan as needed once it is complete. The plan will reflect sector specific priorities and services that need to be provided, and will share information, and identify opportunities to collaborate.

D. USG Strategy and Role

The USG is the largest bi-lateral donor in the health sector. With the withdrawal or reduction in funding from a number of donors following the political crisis, estimates suggest that the USG, with $50.6 million in U.S. Fiscal Year 2012 funds, is providing more support annually than all other active donors in the health sector.

1. Madagascar Mission Strategy

The USAID/Madagascar Integrated Strategic Plan (ISP) of 2003-2008 was extended to 2013. The goal of the USAID Mission ISP for fiscal years 2003 – 2013 is, “Sustainable and Inclusive Economic Development.” This goal aligns with host country priorities, U.S. foreign policy, and overall USAID goals. The strategy underscores the importance of sustainable economic and democratic transformation that benefits all segments of society. In U.S. fiscal year 2012, USAID/Madagascar will begin the development of a Country Development Cooperation Strategy (CDCS) in collaboration with all USG agencies at post. The CDCS will be the governing strategy for the 2013-2018 period. It is anticipated that the USAID goals and objectives in health for Madagascar will not change significantly given recent analyses of health sector outcomes and country priorities. Therefore, the PHC Project is expected to continue to be a logical and necessary component of USAID/Madagascar’s health strategy.

The PHC Project will contribute to achieving the Mission’s Health Sector Assistance/ Development Objective to increase the use of selected health services and products and to improve practices. This objective is strongly linked to strategies outlined under “Investing in People” by: promoting quality of services and products to address reproductive health, maternal, neonatal and child health, and nutrition; reducing infectious diseases (including malaria); promoting improved hygiene practices; strengthening local partners and communities; and, promoting effective coordination of donors and resources.

2. USAID/Madagascar Health/Population/Nutrition Strategy

USAID supports activities that contribute to improvements in health status and a reduction in population growth, both of which are necessary to maintain a healthy population that can productively contribute to economic growth and environmental stability. USAID/Madagascar’s current HPN Office Strategy (2009-2013) envisioned working with the public sector at the national level on training, policy, protocols, behavior change and health systems strengthening while supporting service delivery and strengthening the referral system at all levels in the public, private and NGO sectors. Following the imposition of USG assistance restrictions in 2009, USAID reviewed the strategy and the Performance Management Plan and decided to maintain its goal and elements, while recognizing that the USG will only work through the private, non-governmental and community sectors until the political situation changes and restrictions are lifted. Given the ongoing political crisis, Madagascar has not developed a USAID Global Health Initiative Strategy, but did produce a BEST Action Plan 2011-2015 (see resource page), “Integration for Improved Community Health.” The plan illustrates interventions for integrating and scaling up best practices in family planning and reproductive health (FP/RH), maternal and child health (MCH), and nutrition within Madagascar. This document and the U.S. Presidential Malaria Initiative (PMI) Madagascar Operational Plans[footnoteRef:4], which detail strategy and activities for preventing and treating malaria, provide the most current overview of the USAID/Madagascar health program. [4: http://www.pmi.gov/countries/mops/fy11/madagascar_mop-fy11.pdf]

The overall goal of the 2009-2013 HPN Office Strategy is to reduce maternal and child mortality. This will be achieved by realizing results to increase the use of health services and products and improve health behaviors and practices.

· IR1 - Increase the demand for health products and services

· IR2 - Increase the availability of health products and services

· IR3 - Improve the quality of services provided

· IR4 - Strengthen institutional capacity

The priority technical areas include:

· Integrated management of childhood illnesses (IMCI)

· Essential nutrition actions, improved nutrition practices and household food security

· Diarrheal disease control and improved household access to and use of potable water and sanitation

· Malaria prevention and case management

· Community case management of pneumonia and diarrhea

· Family planning and safe motherhood

· STI/HIV/AIDS prevention

Madagascar is a USG focus country for MCH, FP/RH, and the PMI (See Annex A for technical background and strategy).

E. Other Donors

Madagascar’s key partners and donors include: the World Bank (WB); the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM); the United Nations System including United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), and the United Nations Population Fund (UNFPA); the African Development Bank (ADB); the Agence Française de Developpement (AFD); the German Gesellschaft fur Internationale Zussamenarbeit (GIZ); the European Union (EU) and the Japan International Cooperation Agency (JICA).

Almost all resources from active donors have been reoriented from the central to the district or community level and to NGOs as a result of restrictions which prevent most from providing direct technical or financial assistance to the current GOM. As the political situation evolves, some donors, such as the EU and World Bank, are beginning to re-engage with the public sector.

· MCH, FP, and Nutrition: UNICEF and WHO are key partners for provision of immunization, nutrition, hygiene and sanitation, and integrated management of childhood illnesses (IMCI). UNICEF supports nutrition sentinel sites and WHO focuses on district level health system strengthening, infectious diseases, and neglected tropical diseases. National immunization coverage is at risk due to a lack of donor and GOM funds to address vaccine supply and the deteriorating cold chain. UNFPA provides assistance to the GOM in support of reproductive health and family planning. Their activities include family planning service delivery, contraceptive and reproductive health commodity security, and adolescent reproductive health services. In addition, UNFPA provides support to maternal health activities and purchases delivery kits for the public sector. JICA has strengthened MCH services. USAID also collaborates with the World Food Program (WFP), the UN Food and Agriculture Organization (FAO), and UNICEF in nutrition and food security. The EU is focusing its support for health and education in Anosy, Atsimo Andrefana, Menabe, Sava, and Analanjirofo regions. Health activities are expected to support health center delivery systems.

· Malaria: The Roll Back Malaria (RBM) partnership, of which the USG is a member, facilitates donor synergy and cost effectiveness to support the National Malaria Control Program. Through the RBM, the USG liaises with other donors and NGOs to ensure coordination of efforts. The GFATM and USG, through the President’s Malaria Initiative (PMI) are the largest contributors to malaria activities. In addition, the United Nations Agencies (WHO and UNICEF), International Red Cross, and JICA have committed substantial resources to ensure rapid scaleup of malaria control interventions.

· Water Supply and Sanitation: Water Supply and Sanitation: Madagascar is among the first three countries to benefit from the Global Sanitation Fund (GSF) generated by the Water Supply and Sanitation Collaborative Council (WSSCC). The total financing is $5 million dollars over five years. The program, implemented by Medical Care Development International, covers 20 regional projects. Other key partners in water and sanitation include UNICEF, Wateraid, UNDP, ADB, and Ran’Eau. The national Diorano-Wash partnership brings different departments (health, environment, water) and NGOs together to coordinate quality water, sanitation and hygiene-related activities and approaches.

F. Community Health Volunteers in Madagascar

1. USAID Support

For more than a decade, USAID/Madagascar has been investing in the development of a national Community Health Volunteer (CHV) system to improve access to life-saving primary health care services for rural and remote populations. The USAID-supported Jereo Salama Isika Project, implemented by John Snow Incorporated from 1999 to 2003, provided assistance to the Madagascar Ministry of Health (MOPH) at the central level, Antananarivo and Fianarantsoa provinces, and 23 focus districts. The project used a two-pronged approach to improve the skills and functioning of health providers at the health center and district levels while simultaneously mobilizing communities to change social norms and support local health providers. Jereo Salama Isika provided orientation to about 18,000 community volunteers who conducted health promotion activities (but, no diagnosis or treatment). The project used a “Champion Commune” or “Celebrating Success” approach, sponsoring over 450 festivals to recognize communities that achieved their targets.

The USAID-supported Santénet Project, implemented by Chemonics International from 2004 to 2008, was designed to work closely with the MOPH to achieve the eight major health outcomes defined in the Madagascar Action Plan. The community component, reached 400 communes in 12 regions: Alaotra Mangoro, Amoron’I Mania, Analamanga, Analanjirofo, Anosy, Atsimo Andrefana, Atsinanana, Haute Mahatsiatra, Ihorombe, Menabe, Vakinankaratra, Vatovavy Fitovinany. The service package was broadened to introduce community distribution of Depo-Provera (DMPA), as well as expand community distribution of oral contraceptives, mosquito nets, point-of-use water treatment, and malaria treatment.

Presently, the USAID/Santénet2 Project, implemented by Research Triangle Institute International (RTI), is a five-year $31.9 million Task Order contract that aims to increase access to and availability of high-impact community-based interventions in 800 communes concentrated in eastern and southern Madagascar.

Santénet2 provides local capacity building, training, and supervision to mobilize over 12,000 CHVs in 16 regions: Alotra Mangoro, Amoron’I Mania, Analamanga, Analanjirofo, Androy, Anosy, Atsimo Andrefana, Atsimo Atsimanana, Boeny, Astinanana, Haute Mahatsiatra, Ihorombe, Itasy, Sava, Vakinanakarantra, and Vatovavy Fitovinany. CHVs offer life-saving health services including family planning, maternal, newborn, and child health, as well as malaria prevention and control. In general, two CHVs have been elected by their communities from each of the 5,758 targeted fokonanys located more than five kilometers from the nearest health center.

In FY 2011, Santénet2-supported CHVs provided safe motherhood services including early detection and referral for obstetric and neonatal emergencies to more than 258,000 pregnant women. Project-supported CHVs also delivered life-saving treatment to more than 112,000 children for diarrhea; 90,000 children for pneumonia; and 69,000 children for malaria. CHVs identified and referred 45,830 children with severe malnutrition to local health centers. Furthermore, in FY 2011, Santénet2-supported CHVs provided oral and injectable contraceptives to over 103,000 women.

Mahefa, Santénet2’s sister project, a $35 million five-year Cooperative Agreement implemented by John Snow International Research & Training Institute (JSI) was signed in May 2011. Mahefa is scaling-up support for integrated community-based activities in underserved western and northern Madagascar. Mahefa aims to reach 160 difficult to access and underserved communes in the north and west in FY 2012, and a total of 323 over the life of the project.

The Santénet2 and Mahefa Projects work closely with a national Integrated Social Marketing project currently implemented by Population Services International (PSI). Among other activities, Population Services International (PSI) manages the community commodity supply chain which provides life-saving health products through an expanding network of district and commune-level supply points for distribution by CHVs. PSI is ending in December 2012 and a follow-on Integrated Social Marketing project is presently being procured.

2. Other Donors

UNICEF Madagascar supported the MOH to launch a community-Integrated Management of Childhood Illnesses (c-IMCI) training for CHVs in 2009 as part of a response to a nutrition emergency in the south. One CHV per fokontany was trained, primarily due to the difficulty in identifying literate individuals. UNICEF financed the training and initial stock of equipment and supplies, such as management tools and medicines, and contracted a local NGO to implement the pilot phase. Currently, UNICEF supports the MOH to implement community-based activities in Aloatra Mangoro, Analanjirofo, Androy, Anosy, Atsimo Andrefana, and Melaky regions. These activities focus on health promotion, prevention, and community case management of the most common childhood illnesses of children under five years of age: diarrhea, pneumonia, and malaria.

The national CHV program is further expanding with support from the Round 9 Global Fund grant. The Madagascar National Strategic Application (NSA) grant focuses on community-case management at scale. Specifically, this program aims to identify/recruit, train, supply, supervise, and motivate 34,000 CHVs (two per fokontany, exempting major urban areas) across Madagascar in nearly all 1,549 communes. CHVs identify, diagnose, and treat or refer (for severe cases) children under five years of age affected by malaria, pneumonia, and diarrhea. NSA partners are also training CHVs in Middle Upper Arm Circumference (MUAC) and providing them with the MUAC bands. The NSA project is prioritizing existing CHVs for training. A matching of the Santénet2-supported CHV list against the NSA CHV list shows that nearly all Santénet2-supported CHVs have been trained or retrained under the NSA.

The NSA grant is currently scheduled to end in March 2013. A Phase II grant application is currently under review. If approved, the follow-on project would retain the focus on community service provision using a district-wide approach whereas all communes within each targeted district are supported.

3. National Policy, Local Structures, and Services Provided

National Policy In early 2009, immediately prior to the unconstitutional change in government, the MOPH published the National Community Health Policy (see resource page) to guide the promotion and harmonization of community-based health services by assessing lessons learned from Madagascar’s numerous small-scale health initiatives. The policy’s primary objectives are to increase demand for health-related services, promote their availability, and establish their local delivery. The National Policy is widely recognized as a major advancement towards formalizing, harmonizing, and strengthening a national CHV program to reach the country’s predominantly rural population.

The MOPH and UNICEF have been leading an effort to coordinate the growing number of national level stakeholders supporting community-based activities and harmonize approaches with the aim of strengthening one national system. A series of workshops have been organized to review key challenges including CHV training, supply chain, monitoring, per diems and other incentives. The MOPH is drafting implementation guidelines to clarify and facilitate the harmonization of approaches in these areas.

One particulary contenious issue has been the proposed provision of individual cash performance incentives to CHVs. Following a protracted discussion, a national consenus was reached in mid-November, 2011 to adopt a collective community-level motivation scheme to be managed by CHV Comités de Santé (COSANs). The draft Community Health Policy Implementation Guidelines (see resource page) cite financial motivation as a strategy to support recognition and motivation of community actors. Activities cited under this rubric include the establishment of an account and deposit mechanisms, identification of financing, transfer of resources, and the development of income generating activities.

Local Structures Comités de Santé (COSANs) and Commission Communale de Développement Social (CCDSs) are the local structures that support the implementation of the policy. COSANs, established by Ministerial Decree No 8014 in September 2009, are essentially CHV associations. The Direction des Districts Sanitaires (DDS) estimates that approximately 60 percent of communes presently have a functioning COSAN at the commune-level. However, antidotal information suggests that figure is much lower.

Commission Communale de Développement (CCDSs), established by Ministerial Note No 38 MSAP/SG/DGS/DDS/SSC in August 2010, are comprised of community leaders who coordinate community health activities at the commune level. CCDSs develop annual commune development plans which set priorities and supervise CHVs, holding them accountable to their communities.

Services Provided CHV tasks are distinguished by training level and category. For Mother Health, Level 1 CHVs offer information on FP methods and distribution of the standard days method (using cycle beads), condoms, and pills and refer for long-acting and permanent methods; provide messages on STI/HIV/AIDS prevention, safe motherhood (referral for Antenatal Care, intermittent preventative treatment (IPT), nutrition); and post-partum FP. Level 2 CHVs provide all these services as well as injectable contraceptives. For Child Health, Level 1 Maternal CHVs promote the Essential Nutrition Actions, Growth Monitoring Promotion (GMP), referral for vaccination, and promote malaria, diarrhea, and acute respiratory infection (ARI) prevention messages. Level 2 Child Health CHVs provide all of these services as well as identification and community case management for malaria, diarrhea, and ARI. After six months of practice at level 1, CHVs must demonstrate being able to apply the knowledge/skills acquired during advanced training to be certified as level 2. Madagascar is seeking to upgrade all CHVs to level 2, so the variability between the two levels should cease.

G. Identified Priorities

1. Community Assessments As part of Santénet2’s local capacity development approach, the project catalyzed participatory community assessments in 500 fokontanys, representing 100 communes. A total of 31,705 individuals participated to these meetings: an average of 63 participants per meeting, of whom 60 percent were women. An analysis of these assessments revealed the top three participant identified needs/priorities:

a. Health service availability

b. Drug availability

c. Quality of health services

Another aspect of the local capacity development approach is the empowerment of local stakeholders to find solutions and take action to address their identified priorities. This approach has led to the (unsubsidized) construction of more than 540 health huts. Health huts are a community sponsored ‘benefit’ which provide work space for their CHVs. In addition, some communities required CHVs to display the schedule of working days and hours outside the health hut. With respect to drug availability, communities have also organized to help CHVs resupply health products from the the supply point or health center. They provide seed funds for augmented health commodity procurement (typically during high illness seasons), transport of commodities from the supply point, and monitor commodity stock available at the CHV level. However, funding for commodity resupply at the community level remains a significant challenge leading to persistent stock-outs of select commodities. With respect to service quality, communities have proposed more regular technical supervision of CHVs.

2. Community Health Volunteer Assessment

In order to evaluate program functionality as well as service quality USAID/Madagascar, the Centers for Disease Control (CDC), the Global Health Technical Assistance Project, the Health Care Improvement (HCI) Project, UNICEF, and other partners completed a comprehensive CHV Assessment in September/October 2011 (see resource page for the Qualitative Assessment report). Program functionality was assessed using a standard quality improvement tool; service delivery quality was evaluated by conducting a cross-sectional survey observing CHW performance in delivering services to clients. Preliminary findings are discussed below.

Program Functionality The qualitative component assessed program functionality through a series of participatory stakeholder workshops to systematically investigate and score the following program elements: recruitment, training, equipment and supplies, supervision, performance evaluation, incentives, community involvement, referral system, opportunity for advancement, information management, and linkages to the health system. Several patterns emerged. Recruitment was uniformly scored as a best practice, with comments from different regions indicating that community involvement and/or the application of selection criteria warranted the high score. Such involvement was essentially a community’s participation in selecting a CHV; supervising him/her; awareness rising; and, in some communities, building a hut where the CHV could offer services. As part of the community involvement component, communication at the community level was often faulted for failures to successfully inform community members that CHV services were limited.

Equipment and supplies generally scored low (non-functional in two regions and partially functional in one), with repeated expressions that the government should help more in this area. Exceptionally, three NGOs in one region scored the component as a best practice, citing help from health centers when stock-outs occurred in communities. Relatedly, country ownership scored somewhat low (non-functional in two and partially functional in two), generally for not contributing to CHV efforts other than to provide forms and requiring reports. Weak government support often emerged as a topic in discussions about training, incentives, and the lack of supervision.

Referral systems received high scores, but many comments indicated that CHVs do not receive feedback from health centers to guide follow-up care.

Separate research examined supervision from the perspectives of CHVs, supervisors, and communities. Generally, these three groups saw supervision as helpful in ensuring service quality. They understood the supervision approach and reported that it was a good way to improve services through a combination of control, capacity building, and support to CHVs in problem solving. However, some participants seemed not to see the distinctions between evaluation and broader supervision tasks, such as providing guidance on an as-needed basis.

Recommendations from participating stakeholders call for stronger coordination between the CHV program and other entities: community representatives, the health care center, and the greater public health system. Stronger coordination, participants felt, would generate greater respect for and understanding of CHVs and their activities, more reliable supplies, and better supervision. Stakeholders in one region stressed the need for the use of information generated by CHVs and higher levels of the health care system to inform decision making and action.

Service Quality The cross-sectional survey component of the CHV Assessment evaluated the quality of services delivered by CHVs in c-IMCI as well as the FP counseling. The study assessed adherence to guidelines in caring for patients and identified factors associated with performance. CHVs completed ill-child assessments that were observed by an IMCI expert using a structured checklist, results were compared with a gold standard assessment of the same sick children by a different IMCI expert. All forms, supplies, and medications were made available.

The findings described below are based on preliminary analysis. Factors associated with performance are discussed in Section II.C.3 below.

In relation to uncomplicated fever, CHVs correctly diagnosed the illness in 33-70 percent of the cases depending on the diagnosis, and only 55 percent correctly chose the appropriate life-saving treatment. For uncomplicated diarrhea, CHVs correctly assessed symptoms in 91 percent of the cases; however, only 56 percent were correctly diagnosed, and the correct treatment was chosen for only 51 percent of children (with uncomplicated diarrhea). Respiratory illness had similar results with CHVs correctly assessing the symptoms among 82 percent of cases of uncomplicated pneumonia; however, only 60 percent of cases of uncomplicated pneumonia were correctly diagnosed. The correct treatment was chosen for only 43 percent of children presenting clinical signs of uncomplicated pneumonia.

Referral for severe illness was better. CHVs appropriately referred 68 percent of children with severe diarrhea; 70 percent of children for severe pneumonia; and, 53 percent of children with severe malaria. In relation to the assessment of fever, the study found that Rapid Diagnostic Tests (RDT) for malaria are underutilized as CHVs correctly choose to perform an RDT in 55 percent of ill children requiring an RDT. Among these children requiring an RDT, CHVs correctly interpreted the test results 90 percent of the time, and a correct treatment decision was made 88 percent of the time compared to the gold standard.

In relation to FP counseling, preliminary un-adjusted results show: CHVs properly classified eligibility for Depo Provera (DMPA) use among those choosing this method for 94 percent of the clients seen. Although 98 percent of CHVs know that 16 weeks after the initial injection of DMPA is too late for a second injection, however only 54 percent know to refer the client who returns late for a second injection to the health center to avoid unwanted pregnancy. Only 31 percent reported using patient checklists and having a continuous supply of stock.

3. Key Stakeholder Consultations

To validate national community health priorities and proposed approaches, consultations were held with key stakeholders at both the national and community levels. Several themes emerged during these consultations. Foremost, stakeholders advised that all efforts should build on existing systems and CHV networks and align with established national priorities and policies. Stakeholders strongly recommended that efforts use harmonized and sustainable approaches with the primary aim of integrating and strengthening all CHVs into one national system. Areas needing ongoing coordination include commodity supply, training, motivation, and local systems strengthening.

In relation to access, a continued focus on fokotany more than five kilometers from a health center is essential. The establishment and capacity building of COSANs using an existing training curriculum was noted as a top priority. Furthermore, vertical interventions are discouraged; access should be increased by strengthening the skill set of existing CHVs. To the greatest degree possible, CHVs should be trained to offer the same services and be polyvalent. To ensure they can fulfill their role, CHVs need ongoing monitoring and access to consumables and commodities.

Other issues that were raised included improved communication and reporting mechanisms at each level of the system, inproved referrals for clinical services, and improved engagement of local technical experts.

In relation to motivation, the development of sustainable motivation schemes at the commune level is essential. Likewise, the establishment of an associated social fund will enable communities to better respond to emergencies. Both CHVs and communities should also contribute to a self-managed fund to maximize participation and ownership and COSANs should have opportunities to undertake income generating activities.

In relation to decentralization and community engagement, community stakeholders should be responsible for decision making and determining training gaps and priorities. Maximum feasible participation and engagement of local leaders and community members is a major priority. Many local NGOs are being overextended and donors should help them develop their technical competencies. Thus, implementing partners should facilitate and leverage the technical and programmatic resources of other partners.

C.3. DISCRIPTION OF SUB-PURPOSES, ITS COMPONENTS, KEY INTERVENTIONS, AND EXPECTED RESULTS

1. Sub-Purpose 1: Sustainably develop systems, capacity, and ownership of local partners

Local systems, capacity, and ownership compel responsibility which catalyzes action to improve health practices. These outcomes foster sustainability. The chance of sustaining project-facilitated health improvements is greatest when local system actors have sufficient capacity and viability to carry out the key tasks needed to produce key health outcomes within an enabling environment.[footnoteRef:5] The PHC Project will strengthen local systems and implementing partners with the aim of empowering them to be self-reliant to the greatest degree possible. Women’s engagement, empowerment, and leadership is also critical to the success of this objective and must be improved. Please refer to Section C.4 Cross-cutting design elements (below) regarding sustainability and gender. Local capacity development (LCD) approaches and interventions considered essential to the PHC Project are described below. [Additional innovative approaches may be proposed by Offerors.] [5: Eric Sarriot, Jim Ricca, Jennifer Yourkavitch, Leo Ryan, and the Sustained Health Outcomes (SHOUT) Group. (2008). Taking the Long View: A Practical Guide to Sustainability Planning and Measurement in Community-Oriented Health Programming. Calverton, MD: Macro International Inc., September 2008

Local Capacity Development Approaches

A. Strengthening Local Systems In relation to community capacity and viability, key factors necessary for continued service provision through CHVs include local leadership, participation, and ownership within the context of established systems. Community decision making fosters ownership, which in turn engenders accountability and action. Santénet2 has established and strengthened CCDSs in health governance, leadership, planning, monitoring and reporting in 800 communes. Building on these accomplishments, it is essential that the PHC Project further strengthen community capacity and viability through several approaches including: (1) facilitating the re/establishment of COSANs and CCDSs where they do not presently exist; (2) provision of targeted capacity development assistance for COSANs and CCDSs to ensure their functionality; and, (3) facilitating the creation of sustainable motivation schemes. Each intervention is further described below. [Additional interventions may be proposed by Offerors.]

Required Interventions

1. Establishment of Comités de Santé or Health Committees (COSANs).[footnoteRef:6] COSANs will formalize, organize, and strengthen CHV networks. Although the DDS estimates that 60 percent of communes have a functioning COSAN, this figure is likely to be substantially lower. In relation to CCDSs, these structures are already established in communes currently receiving assistance from Santénet2. New communes will likely need assistance to establish both COSANs and CCDSs. [6: reference Ministerial Decree No. 8014/2009 on the creation, organization, and functioning of COSANs]

2. Targeted assistance to develop local capacity for COSANs and CCDSs to ensure their functionality and good governance structures. This is expected to improve local supervision, reporting, and referral systems.

3. Catalyze the establishment of sustainable motivation schemes for CHVs. There is strong evidence that Village Savings and Loans Associations (VSLAs) can increase savings and access to credit, improve community status and social cohesion, promote empowerment, generate high levels of meeting attendance, and mitigate attrition. These outcomes are of interest as they are also important factors that motivate individual CHVs, strengthen their linkages, and reinforce systems. Specifically, the PHC Project will lead the development and implementation of two microfinance approaches as described below. USAID/Madagascar plans to independently evaluate the impact of these interventions. [Offerors may propose additional innovative approaches.]

3.1 Drawing from international and Madagascar specific experience, the PHC Project will facilitate the establishment of commune-level COSAN Savings and Loans Funds (CSLF). These funds will need to support and align with the MOPH Community Participation Policy Implementation Guidelines. Key principles are (1) inclusion, (2) local capacity development, and (3) decentralization and empowerment. Each aspect is further detailed below:

a. Inclusion- The fund should be available to all active CHVs on an opt-in basis. Inclusion of all CHVs is intended to promote cooperation and group cohesion. Additionally, it will help allign all future support for community health activities from the various health development partners, thus reinforcing one CHV system. Opt-in in an important aspect to enable the CSLF participants to select themselves.

b. Local Capacity Development- Simple guidelines and low-literacy training curricula will need to be adapted and rolled out; tools can be borrowed from existing projects. As is currently practiced with VSLAs, training, lock boxes, registers, calculators, etc.. as well as follow-up monitoring and coaching should be considered. The CSLF should prioritize micro-credit loans to CHVs, the fund could also be used as collatoral for Microfinance Institution (MFI) loans described below. To ensure the long-term solvency of the CSLF, a complementary social fund will be established. The social fund may support emergency transport for urgent referral cases, purchase of resupply for health commodities through the community supply chain, construction of a health hut, funerals, or other purposes as determined by each COSAN.

c. Decentralization and empowerment- Responsibility for the establishment, management, and use of the CSLF should rest with each COSAN. To promote ownership of the fund, each COSAN should establish its own rules to the greatest degree possible. The fund will primarily grow through regular monthly financial contributions from each participating CHV member. However, a match from both the community (unlimited) and project (limited) is highly recommended to: (1) stimulate and catalyze the creation of the CSLF; (2) maximize the number of CHVs opting in; (3) distinguish the fund from other VSLAs; and (4) motivate community participation in the provision of CHV ‘benefits’.