SPECIAL NOTICES - LHESS_signed 15FEB2023.pdf

SPECIAL NOTICES

REQUEST FOR INFORMATION (RFI)

LOCAL HEALTH SYSTEMS SOLUTIONS (LHESS) ACTIVITY

USAID/Liberia is pleased to present a draft Activity Concept to provide stakeholders an opportunity to enhance the Local Health Systems Solutions (LHESS) activity design. USAID/Liberia welcomes comments on the entire document, including responses to the questions attached to the cover letter.

The draft Activity Concept is anticipated to result in finalizing either a Statement of Work or a Program

Description that may lead to a formal solicitation or Notice of Funding Opportunity. The place of performance is Liberia. The potential period of performance is a total of five (5) years: two Base years with three optional

Renewal years. The draft Activity Concept is provided in the following pages.

DISCLAIMER

This is a Request for Information only. It is not a Request for Proposal, Request for Quotation, an Invitation for Bids, a Solicitation, or an indication that USAID/Liberia will contract for the services. The RFI is an attempt to reach out to the market to determine the scope of industry capabilities and interest and will be treated as information only. In accordance with FAR 15.201(e), responses to this notice are not offers, and cannot be accepted by the Government of the United States to form a binding contract. Responses are strictly voluntary, and USAID will not pay respondents for information provided. Responses will not be returned, and respondents will not be notified of the result of the review. It is the respondent’s responsibility to monitor www.sam.gov or www.grants.gov for the release of any further information. Note that responding to this RFI will not give any advantage to any organization in any subsequent procurement or funding opportunity. No telephone calls will be accepted, nor will any questions regarding this notice be entertained.

INSTRUCTIONS

To respond to this RFI, interested sources must provide not more than seven (7) pages in Microsoft Word or PDF format by Wednesday, March 8, 2023, 11:30 AM, Liberian time. Please submit responses to Ruth D.

Caesar-Hne, Acquisition & Assistance Specialist at rcaesar-hne@usaid.gov with copies to Garth Patterson, Contracting Officer at gpatterson@usaid.gov and Acquay K. Kamara, Procurement Agent at akamara@usaid.gov. Interested sources must provide the following information:

✔ A capability statement inclusive of information and evidence of programming to support the three (3) objectives mentioned in the attached activity concept.

✔ Responses to questions posed outlining sources of information; and

✔ Additional comments or suggestions on the concept, if any.

Sincerely

Garth Patterson Contracting Officer http://www.sam.gov/ http://www.grants.gov/ mailto:rcaesar-hne@usaid.gov mailto:gpatterson@usaid.gov mailto:akamara@usaid.gov

Questions For Feedback:

USAID/Liberia seeks information from prospective applicants/offerors, including local organizations/institutions, which have relevant, demonstrable experience with approaches to achieving the objectives of the draft Activity Concept.

Please review the enclosed draft Activity Concept. The following questions can be used to guide any feedback, and respondents may answer any or all as they choose:

1. What support do local Liberian organizations working in health need to be able to accept and manage funding from the United States Government?

2. How can decentralized management of the health system in Liberia be effectively implemented?

What support is needed at the county, district, and health facility levels of the county health team to improve technical and financial management?

3. What are the barriers that prevent health governance boards from being fully functional? What can be done to overcome these barriers?

4. What additional skills or resources do health workers need to be able to better perform their jobs?

5. What aspects of the proposed results framework could be accomplished by local Liberian organizations, either alone or working together as a consortium?

6. What needs to be done to improve the management of drugs and medical supplies at the county, district, and health facility levels?

7. How can transparency and accountability of health commodities and funds disbursed to the subnational level for health system management be improved? Are there any roles for civil society actors and organizations? What do civil societies need to play their roles effectively?

8. What are other major health system challenges that USAID could address?

9. Will achieving the intermediate results and sub-results lead to the achievement of the overall goal? Are there issues or aspects that are missing?

10. What is required to ensure that gains made under this health system activity are sustained?

Local Health Systems Solutions (LHESS) Activity

Purpose for the RFI

The purpose of this Request for Information (RFI) is to solicit feedback for USAID’s investment related to an anticipated Local Health Systems Solutions Activity in Liberia.

Draft HSS Flagship Activity Description

ACTIVITY TITLE

Local Health Systems Solutions (LHESS) activity.

INTRODUCTION

Health Systems Strengthening (HSS) is critical to achieving USAID and the Government of Liberia’s (GoL) goals for the reduction in maternal and child morbidity and mortality by improving the quality of healthcare services. HSS is also fundamental for supporting country commitments to the Sustainable Development Goals, including target 3.8 that calls for achievement of Universal Health Coverage by ensuring financial risk protection, access to quality data and essential health care services including diagnostics, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.

USAID intends to support the MoH in strengthening critical components of the health system to improve access and affordability, thus increasing patient outcomes at all levels. Key to accomplishing this task will be strategic engagement with local stakeholders to devise more efficient solutions to ensure quality and equitable healthcare services. USAID anticipates providing a limited package of technical assistance to the MoH to ensure alignment with national priorities and processes that will inform implementation at the subnational level – counties, districts, and health facilities. An important component of the HSS flagship activity will be supporting efforts to strengthen laboratory systems and health information systems. The LHESS activity will also support health financing reform priorities, including the Liberia Health Equity Fund (LHEF), for increased access to quality health services without undue financial burden to patients.

More importantly, the USAID LHESS activity will provide strategic wrap-around technical assistance to the USAID Health Partnership activity in the eight G2G focused counties. Technical assistance will be provided for the roll-out and operationalization of the performance-based financing approach. Critical technical assistance will be provided for the introduction of the LHEF legislation and to strengthen the quality of laboratory services at the subnational levels. The USAID LHESS activity will prioritize data quality improvement, reporting, and analysis for decision making and training of health staff in select technical areas for the delivery of safe and effective health services.

The LHESS activity will respond to the World Health Organization’s six building blocks for effective and efficient health systems performance, as the building blocks work together as a unit, each depending on the performance of the other.

1. Leadership and governance (decentralization management, monitoring and supportive supervision, and health system accountability)

2. Health Workforce (skill improvement and competency enhancement for a high performing health workforce)

3. Health Information Systems (integration and interoperability of data systems, data quality, analysis, reporting and use for informed decisions).

4. Access to essential medicines (management of medicines and supplies at the subnational level)

5. Health financing (public financial management, performance-based financing, domestic resource mobilization, and LHEF legislation for increased access to health services)

6. Service Delivery (disease surveillance, diagnostic capacity strengthening, and quality improvement for increased coverage and access to safety and respectful health services)

The Mission will continue to advocate with other donors and USAID funded activities for improved supply chain management at the central MoH level and specific components of human resources for health, primarily planning and management of the health workforce.

BACKGROUND

Liberia ranks 173 of 184 countries in the world on the Human Development Index report (HDI, 2022).

Access to quality health services, coupled with education, household wealth, electricity, and sanitation facilities, remains a strong indicator of health outcomes in Liberia. Critical health indicators related to child and newborn health are not performing well. However, data from the 2019/2020 LDHS shows that some other indicators have shown improvements over the past 12 years. For example, the percent of pregnant women who received prenatal care by a skilled provider increased from 96% in 2013 to 98% in 2019, while births occurring in a health facility rose from 56% in 2013 to 80% in 2019. Meanwhile, births attended by a skilled provider increased from 61% in 2013 to 84% in 2019.

USAID supports the building of strong and resilient health systems that are effective and efficient and promotes access to high quality health services. A resilient health system is critical to meeting the requirements for provision of quality health services in Liberia. Strong health systems are key to improving access to affordable and safe health services, moving Liberia closer to universal health coverage. A strong health system also leads to sustainable improvements in health outcomes and ultimately will contribute to the economic growth and stability of Liberia.

The Government of Liberia (GOL) prioritizes decentralization as an approach to improving access to quality health services. This approach, when fully implemented, will empower leaders at the subnational level to make the decisions required to drive health systems improvement.

Current and Past USAID Interventions

USAID has been a steadfast supporter of Liberia’s efforts to strengthen the capacity of the health system to deliver basic services following the civil war. In 2004, USAID resumed its investments in health development with an initial focus on restoring basic service delivery that then expanded to support broader health system functions at the national and sub-national levels.

The Country Development Cooperation Strategy (CDCS) 2019–2024 outlined a two-tiered approach for providing both technical and financial assistance for the implementation of the MOH’s National Health policy and Plan (2022-2031):

1. National-level investments in MOH capacity building and technical assistance for policy formulation, strategy development, and systems strengthening – including management and oversight capacity, and governance and leadership.

2. Immense investments across the fifteen counties to strengthen the health system, including expansion and improvement of facility-based services, capacity building of county and local health authorities in each county to manage resources, introduction and scale-up of global best practices, and piloting innovative interventions to generate evidence to inform national policies and strategies. This support was expanded in 2015 into additional counties with post-Ebola supplemental funding.

USAID’s partnership with Liberia has pioneered the use of an innovative government-to-government (G2G) agreement for channeling U.S. assistance for health service delivery directly through the Government of Liberia (GOL)’s health system, building the health system’s capacity in stewardship and management at the national and sub national levels.

Liberia became a USG President’s Malaria Initiative (PMI) focused country in FY 2008. The country has received an annual budget of $14 million for the last four years totaling almost $160 million from 2008 to 2019. Most of the support goes to procurement of malaria commodities: bed nets, malaria test kits, and malaria drugs. Liberia contributes to PMI’s global long-term vision of a malaria free zone in Africa, and goal of worldwide malaria eradication by 2040-2050, through scale-up of three of the four proven and highly effective malaria prevention and treatment measures: insecticide-treated mosquito nets (ITNs);

accurate diagnosis and prompt treatment with artemisinin-based combination therapies (ACTs); and intermittent preventive treatment of pregnant women (IPTp). To reach a critical mass with proven and highly effective malaria prevention and treatment measures and to reduce the malaria burden in Liberia, PMI Liberia is scaling-up geographic coverage to strengthen malaria services delivered, improve data collection, management, and dissemination to guide the national malaria control program. Therefore, LHESS will play a pivotal role in supporting the PMI interventions in Liberia to improve malaria case management and malaria in pregnancy. This activity will also be expected to support the introduction and scale-up of the malaria vaccine in Liberia and support mosquito net distribution as needed.

The Ebola Viral Disease outbreak of 2014 revealed that the Liberian Healthcare System was weak and not prepared to respond to emerging diseases affecting the Globe. Through the Global Health Security Agenda, the USG has supported the MOH to prepare for and respond to infectious diseases through strengthening of laboratory and surveillance systems. Technical assistance is provided to the National Reference Laboratory and regional laboratories for increased diagnostic capacity and enhanced surveillance for early disease detection and response. This activity will be expected to enhance these efforts especially at the subnational level.

Relationship to the Government of Liberia Strategy

This activity will contribute to the GOL’s Pro-Poor Agenda for Prosperity and Development (PAPD) priorities specifically Pillar One: Power to the People health outcomes. The PAPD also outlines a health system strengthening approach with a focus on five dimensions of health system performance including:

Equity, Quality, Responsiveness, Efficiency and Resilience.

All support will be in line with Liberian national and county health policies, standards, county operational plans, and MOH contracting-in priorities. The activity will build and capitalize on the accomplishments and lessons learned in the pre-COVID-19, during the pandemic, and after the pandemic regarding systems strengthening, including from previous USAID supported HSS activities such as the Rebuilding Basic Health Services (RBHS), Collaborative Support for Health Systems Strengthening

(CSH), and the current HSS flagship activity, the Strategic Technical Assistance for Improved Health Systems Performance and Health Outcomes (STAIP).

In 2016 with support from USAID, the MOH made a strategic shift from contracting-out delivery of health services to international NGOs, to contracting-in delivery of health services directly to County Health Teams (CHT) for a more sustainable, low-cost model of service delivery. The MOH in its Contracting-In Guidelines (2016) notes, “the intent is to gradually reduce the role of Not-for-Profit (NFP) providers and increase the role of CHTs in managing government facilities. CHTs may, in turn, contract directly with government health facilities for service delivery as well as with privately owned facilities (primarily non-governmental and faith-based).

In all instances where contracts are used, emphasis will be placed on establishing distinct catchment populations in each health system to ensure appropriate allocation of resources and measurable performance.” Contracting-in is an effort that contributes to and aligns with the MOH Decentralization Policy, which gives more resources and autonomy to county health teams. Capacity building efforts directed towards the CHT’s can include complementary policy/advocacy activities working with the national government to increase CHT’s autonomy and access to resources.

This will also include working with county and district health boards to ensure that leadership at the sub national level is strengthened for strategic collaboration and coordination. Additionally, the MOH adopted a Policy Recommendation on Strategic Implementation of the LHEF in December 2017 to prioritize health financing in three major areas: 1) domestic resource mobilization, 2) strategic purchasing and pooling, and 3) introduction of user-fees for sustainable health financing and ensuring financial protection of the poor. This activity will directly contribute to the above listed policy recommendations.

LINK TO CDCS

This activity will support the achievement of USAID/Liberia’s CDCS DO3: “Foundations for growth strengthened through a healthy, productive, and educated population,” specifically through contributions to IR 3.1: Quality of health, HIV, nutrition, and WASH services improved and IR 3.2: Health/nutrition and WASH systems at national and sub-national level strengthened. The LHESS activity will also contribute to PMI’s goal of reducing malaria morbidity and mortality in Liberia, and GHSA’s goal of promoting global health security through improving laboratory systems, enhancing real-time disease surveillance, and increasing Liberia’s capacity to manage health emergencies of a pandemic nature.

LINKS TO OTHER ACTIVITIES

USAID implements a three-pronged approach, supporting facility level integrated health service delivery in addition to community-based health services, buttressed by systems strengthening interventions to ensure comprehensive support for the health sector. The G2G Partnership mechanism focuses on strengthening decentralized service delivery for RMNCAH and malaria services. USAID/Liberia’s Community Health Activity supports the implementation of the Ministry of Health Community Health Policy and activities in targeted geographic areas, including community-level service delivery strengthening. It also seeks to increase demand for, and use of health services at the facility level while ensuring community accountability of health services.

This USAID LHESS activity will ensure a coordinated environment to plan, manage, monitor, and support the MOH to implement its mandate, including increasing capacity for local engagement and mobilization of domestic resources for the health sector. The activity will leverage other activities in the same geographic areas to prevent duplication as it coordinates HSS interventions with the Global Fund, World Bank, and other development partners to maximize donor support for improved health systems performance across the country and ensure non-duplication of efforts at the central and county levels.

OBJECTIVES

The LHESS activity will seek to achieve the following key objectives:

1. Strengthened Decentralization Structures at national and subnational level to drive health system performance.

2. Strengthened systems for delivery of quality health services; and

3. Increased financial protection through reduced out-of-pocket spending on health care.

Cross-Cutting

1. Data Systems for improved quality, analysis, reporting, and use strengthened, and

2. A Responsive Technical Assistance Fund to ensure flexibility in USAID Technical Assistance established.

OBJECTIVE 1: Strengthened Decentralization Structures at national and subnational level to drive health system performance

Decentralization is the number one policy objective of the MoH as stated in the National health Policy and Plan 2022 - 2032. This approach is intended to de-concentrate MoH management responsibilities to the sub-national level. The policy states that a stronger governance and leadership structure will be built from the top; while management responsibilities, along with resources and authority, will be devolved to the lower levels of the healthcare system. County Health Teams will be transformed into Health Departments and placed under each county administration. The LHESS award will be expected to support the decentralized system to achieve the below listed intermediate results.

IR 1.1: Enhanced Public Financial Management for planning, implementation, and accountability of program funds at county, district, and health facilities

All fifteen counties receive funding from several sources, including the USAID G2G mechanism, for implementation of interventions related to better health outcomes. Based on this, interventions are expected to enhance financial management practices in compliance with GOL financial management standards as a requirement for best practice. The potential applicants/offerors will be expected to outline interventions that will improve public financial management and accountability. USAID expects the potential implementing partner to strengthen the capacity of sub-national level health teams to plan, implement, and account for all funds intended for delivery of quality services at the lower level. This activity will also be expected to coordinate with Global Fund, the World Bank, and other donors and partners within target areas to respond to financial risks identified in the health system capacity assessment report. USAID places a premium on a whole of system approach in financial management at all levels. This means that CHT/DHTs and health facilities should be accountable for all funds disbursed to the counties for delivery of health services, hence the need for a coordinated approach to improving financial management.

Expected results under this IR are:

● R1.1.1 Compliance with GOL/MOH Public Financial Management Standards o SR1.1.1.1: By the end of Year 3, target counties are 90% compliant with all 12 PFM functions as per the GOL/MOH revised (2021) Public Financial Management Manual

● R 1.1.2 Reduction of financial risks at subnational levels o SR1.1.2.1: By the end of Year 3, at least 90% of all high risks identified in the National

Health Capacity Assessment are resolved at the central MoH level o SR 1.1.2.2: By the end of Year 3, at least 70% of all high risks identified (per county) in the National Health Capacity Assessment are resolved cumulatively across the counties

IR 1.2 Improved performance of Health Governance Boards for oversight of quality health service delivery in implementation counties

The National Health Policy and Plan (2022-2031) states that “the overall decentralized governance system and county and district health teams are not yet at full capacity to manage the health system” at the sub-national level. Health Governance Boards are either non-functional or not supported to provide oversight of health service delivery as stated in the Decentralization procedures and guidelines. The health governance Boards (county, District, Hospital, health facility development committee) are expected to advise the implementers of health services in the county, assist with resource mobilization and coordination, and monitor the implementation of health plans. USAID expects that potential respondents will propose approaches to support capacity improvement of Health Governance Boards to drive local leadership and accountability for quality health service delivery as per the Decentralized Leadership, Management, and Governance operational Guidelines. The successful applicant/offeror will be expected to coordinate with the MoH County Health Services and Decentralization Units to achieve this intermediate result. Interventions under this IR will be done in collaboration with the G2G Partnership activity and with other donors and partners such as the Global fund and World Bank working in the target counties to prevent duplication.

Expected results under this IR are:

● R 1.2.1 Health Governance Boards functional and are effectively and efficiently providing oversight for delivery of quality health services o SR 1.2.1.1 By the end of year 2, County Health Boards are effectively performing the roles and responsibilities outlined in the decentralization guidelines o SR 1.2.1.2 By the end of year 2, District Health Boards are effectively performing the roles and responsibilities outlined in the decentralization guidelines o SR 1.2.1.3 By the end of year 2, Hospital Boards are effectively performing the roles and responsibilities outlined in the decentralization guidelines o SR 1.2.1.4 By the end of year 2, Health Facility Development Committees are effectively performing the roles and responsibilities outlined in the decentralization guidelines

Objective 2: Strengthened Systems for Delivery of Quality Health Services

The IRs under this objective will provide wrap-around technical assistance in the eight G2G counties and the seven non-G2G counties. The IRs of objective 2 will specifically support the achievement of maternal, child and adolescents’ health and family planning, President’s Malaria Initiative, and Global Health Security Agenda technical assistance priorities. These IRs will align with and support the priorities of the Ministry of Health with focus on the unique needs at the sub national level. A limited package of technical support will be provided to relevant units at the central MoH to enhance oversight and coordination of implementation at the lower levels. The goal of objective 2 is to reinforce institutionalization of quality management processes as per the National Quality Management Strategy.

The below IRs will support the PMI scale-up plan to Rivercess, Sinoe, and Gbarpolu counties. Since the World Bank, through its PBF approach, supports other aspects of system strengthening in these counties, PMI scale-up will be done in collaboration and coordination with the MoH, WB, and other partners providing interventions in these counties to prevent duplication and maximize funding to each county.

Moreover, the IRs will support the GHSA priorities for Liberia including laboratory and disease systems strengthening, and Health-emergency management.

IR 2.1 Increased Access to Quality Health Services

Using the existing systems coupled with innovative local solutions, this IR will seek to provide structured, data-driven, technical assistance for improved quality management processes at the county, district, and health facility levels for delivery of improved RMNCAH, malaria, and laboratory services. This IR will also support improved health systems performance for real-time surveillance and responding to health emergencies such as the COVID-19 and other pandemics.

The continuum of care for all conditions related to RMNCAH and malaria including diagnostics capacity and early referral for advanced care will be addressed under this IR. The Ministry of Health and USAID have invested heavily in Quality Assurance and Quality Improvement interventions as outlined in the National Quality Strategy, therefore results under this IR should build upon historical investments.

Expected results under this IR are:

● R 2.1.1: Quality Assurance and Quality Improvement basic standards outlined in the National Quality Strategy institutionalized o SR 2.1.1.1: Quality management teams are functional to drive quality improvement at all levels by the end of year 2

● R 2.1.2.: Increased Capacity of local Organizations to monitor quality of care improvement o SR 2.1.2.1 At least 6 local organizations can efficiently and effectively plan for, monitor, and report on QA/QI compliance across target counties by the end of year 2 o SR 2.1.2.2 At the end of year 3 at least 4 local institutions can apply the steps required for a sub-award from a USAID supported implementing partner o SR 2.1.2.3 At the end of year 4, at least 2 local organizations are implementing a QA/QI subaward under this activity

● R 2.1.3: Strengthened Referral Pathway for increased health system responsiveness to the needs of patients and families o SR 2.1.3.1 By the end of year 2, the MoH has disseminated a clear referral pathway including feedback loop for the transfer of patients within the health system o SR 2.1.3.2 Health workers are implementing the approved Referral Pathway at the subnational level for timely transfer of patients for better health outcomes

● R 2.1.4: Technical Capacities and Competencies of health workers Increased for delivery of safe services

IR 2.2 Environment for delivery of respectful Reproductive, Maternal, Newborn, Child, and Adolescent Health services Enabled

Under this activity, the potential applicants/offerors will be expected to propose interventions intended to reduce maternal and newborn morbidity and mortality and increase family planning uptake across the target counties. The intention is to build on the gains made in previous HSS efforts aimed at improving the delivery of RMNCAH related services. Specific tasks under this activity would respond to gaps associated with health worker knowledge, focused on improved systems for early detection and referral of women and children and Family planning counseling. This activity will also support interventions to mitigate gaps in health workers’ knowledge related to maternal and newborn health service delivery, as well as increased compliance in the use of standards and protocols for the improvement in delivery of quality services. Under this IR, the potential applicants/offerors will be expected to system strengthening interventions intended to improve the systems for implementation of the G2G partnership in the G2G counties, while in the non-G2G counties support will be focused on direct service delivery coordination with the county, district, and health facility teams to enhanced health outcomes of women and babies in the target geographic locations. Specific results will be jointly developed in partnership with USAID and

MOH.

IR 2.3 Environment for Implementation of Standard Malaria Interventions for improved Patient Outcomes Enabled

The implementer will be expected to support malaria interventions for 7 counties (4 existing and 3 new counties for PMI scale up under this award). The intention is to build on the gains made in previous HSS efforts aimed at improving the delivery of malaria related services. Specific tasks under this activity would respond to gaps associated with health worker knowledge, focused on malaria in pregnancy, prevention, and case management, as well as gaps in availability of materials such as protocols and job aids. Under this IR, the implementer will be expected to support systems improvement for delivery of malaria services in coordination with the county, district, and health facility teams. The award will be expected to work with the World Bank and other partners in the space, especially in the three new counties, to enhance malaria outcomes in women and children in the target areas. The implementer will work closely with the National Malaria Control Program (NMCP) to build up their capacity for oversight of malaria interventions.

Specific intermediate results and sub intermediate results will be jointly developed in partnership with USAID, PMI, and MOH.

IR 2.4 Laboratory and disease surveillance systems compliant to the minimum quality standards as per the National Quality Strategy increased

The MoH has prioritized strengthening of the national laboratory system and diagnostic services in the 2022-2031 National Health Policy and Plan. Significant diagnostic capacity gaps in the structure of the laboratory network have been identified including limited human resource capacity in quality and quantity, stockouts of reagents and lack of functional equipment, etc. About 62.7% of laboratory personnel are laboratory Aides and 13.5% are Laboratory Assistants. This reduces access to quality diagnostic services for patients seeking health care in Liberian health facilities. For example, only 29% of public health facilities have the capacity to perform cross matching for blood transfusion, test for hemoglobin (18%), test for parasites in stool (22%) and (70%) check for malaria10. The 2019-2024 National Laboratory Strategic has two key goals:1) strengthen and expand comprehensive and integrated public health diagnostic systems, and 2) ensure quality clinical laboratory and diagnostics services at all levels of care. The applicants/offerors are expected to propose solutions for the effective functioning of the clinical laboratory system as outlined in the national lab strategy. Technical assistance through this award will support capacity strengthening for improved Antimicrobial Resistance, sample packaging and transportation, and interventions for increased disease surveillance and response to emergencies of a pandemic nature. Specific results will be jointly developed with USAID, GHSA, and

MOH.

OBJECTIVE 3: Increased financial risk protection for equitable access to improved quality of health services

IR 3.1: Development and testing of Health Financing Reforms in line with the Liberia Health Equity Fund priorities

Intervention under this IR will support Central MOH and other relevant stakeholders to prioritize interventions based on the strategic approach outlined in the GoL/MoH health financing strategy. Strong consideration is for the development and testing of ideas related to the operationalization of the LHEF.

The implementer will further support the MoH as decisions are made on feasible short and long-term interventions for the reduction of out-of-pocket spending on health care and overall better financing of healthcare in Liberia.

Results under this IR include:

● R 3.1.1: LHEF legislation enacted o SR 3.1.1.1 Test and evaluate new approaches based on the LHEF Legislation that will contribute to increased risk protection and more efficient and effective health service purchasing o SR 3.1.1.2 Increased advocacy and dissemination of the LHEF Legislation information

IR 3.2 Strengthened Performance Based Financing (PBF) Operations

The MOH implements a PBF approach to reimburse achievement of both select health service delivery and health systems strengthening indicators as outlined by the MOH PBF Manual. The potential implementer will be expected to propose interventions for the full dissemination and implementation in the 8 G2G counties. The implementer is expected to ensure a routine feedback loop between PBF and LHEF discussions. The existing PBF model is used to incentivize better quality of care at the facility level and management at the county health team levels including the percentage of primary health care facilities that would implement PBF for quality improvement. USAID already has a G2G agreement with the Government of Liberia to provide funding to public sector facilities under the Ministry of Health.

However, the implementer must propose an implementation and management approach in support of the G2G Partnership activity implementation of the PBF.

CROSS-CUTTING IRs

CC IR 1: Data Systems for improved quality, analysis, reporting, and use strengthened

Data quality and use is vital to improve both systems performance and drive improved quality of care.

Results under this IR will support the Ministry of Health’s goal as outlined in the Liberian Health Information Systems & ICT Strategic Plan (2016-2021), the National Health Information System of Liberia will produce quality data and information used in support of the health system functions at all levels, with a solid governance and management structure, using appropriate information and communication technology, including data confidentiality and security, at an affordable cost to the Government of Liberia.

Specific health information subsystems that support data for decision-making at the central MOH and county health teams includes the District Health Information System 2 (DHIS2) for routine reporting, integrated disease surveillance and response system (IDSR) for reporting priority and notifiable diseases, logistics management information systems (LMIS) for supply chain management, integrated Human Resources Information Systems (iHRIS), and laboratory information system. Specific results will be determined by the MOH, USAID, PMI, and GHSA.

CC IR 4: A Responsive Technical Assistance Fund to ensure flexibility in USAID Technical Assistance Established

Twenty percent of the award TEA will be set aside as flexible funds for adaptive, responsive technical assistance to address gaps identified at both national and subnational levels in meeting their functional responsibilities. This CCIR will support achievement of results of each of the major IRs, especially supporting quality improvement at health facilities. During implementation, gaps identified during supportive supervision and monitoring visits will be mitigated using the proposed responsive technical assistance funds that ensures accountability by all parties including the MOH and recipients of the TA using a method that ensures quality control of all products delivered under this mechanism. The potential applicants/offerors will suggest an approach that will be simple and almost void of bureaucracy that hinders effective and timely response to mitigate critical gaps. The RTA funds will be used to support interventions that contribute to the achievement of PMI, GHSA, and MCH/FP activity purposes. Results under this IR will be determined by the TA needs that arise because of monitoring and supportive supervision visits. The main result is to make funding available to respond to identified gaps.

USAID-Liberia expects to achieve the stated objectives through a robust localization approach centered on use of the MoH decentralized structures. Moreover, local organizations such as health regulatory bodies (Liberia Medical and Dental Council, Liberia Board for Nursing and Midwifery, Pharmacy Board, etc.), health associations (Liberian Midwifery Association, Liberian Nurses Association, Liberian Medical and Dental Association, Liberian Association of Medical Laboratory Technicians and Liberian Pharmacy Associations, etc.), and local public universities will be engaged and empowered to drive health systems performance at the sub-national level. USAID will also engage with small, local organizations, and other local health NGOs, with expertise in specific technical areas for monitoring of systems performance for quality improvement and increased access to affordable, high-quality health services. This activity will apply a transitional leadership approach by providing sub-awards to local organizations to implement significant (at least 50%) portions of the activity with the aim of building their capacity.

ASSUMPTIONS

The following are USAID’s assumptions:

1. That the GOL will continue to prioritize strengthened decentralized management of health services, contracting-in, and reintroduction of user-fees, and other domestic resource mobilization efforts for increased resources to the health sector

2. That the GOL will resolve supply chain and human resources for health issues, which if not resolved will affect systems performance vis-a-vis delivery of quality services

3. That donor (s) contributing to RMNCAH, malaria prevention and control, and health systems strengthening in Liberia will continue their investment at the current funding level

4. That the GOL will pay salaries of health workers that are on GOL’s payroll

The assumptions listed above will be revisited periodically during the Performance Management Plan (PMP) review to help determine why results are (or are not) occurring and during the development of the next CDCS (the current CDCS ends in 2024).

Activity Development Hypothesis:

Through targeted, data-driven technical assistance to the MOH for policy implementation, and through the use of local solutions to support sustainable interventions at the sub national level, the performance of the health system in focused geographic areas will improve and ultimately promote access to quality health services for better outcomes of the population in those specific geographic areas.

Therefore, the below sections reflect areas of results to be achieved by the end of the award. Each result and respective percentages reflect the expected amount of effort and budget allocations for the achievement of results.

For each intermediate result, the potential applicants/offerors will be expected to detail the number of beneficiaries to be reached along with anticipated costs to allow cost-benefit reviews. Additionally, the potential applicants/offerors must describe how they will delineate and monitor implementation of the award at the Central MOH, and CHTs/DHTs, along with approaches to achieve the expected results. The potential applicants/offerors will indicate ties to previously implemented and complementary interventions by the MOH, USAID, and other cooperating partners, as available, in addition to building on lessons learned from previous HSS activities (USAID and non-USAID supported).

The activity must define and support key interventions/approaches that will drive the technical assistance and achieve the expected results. Proposed approaches will maximize value for money through strategic partnerships within the sector, such as coordination with the USAID PSE activity and the World Bank in the same geographic location and other non-traditional partners) and must integrate gender considerations into all aspects of future programming.

The activity is expected to accelerate improved decentralized management of health services with a focus on local ownership and enhanced leadership, mainly at the district level. It will provide specific expertise that influences implementation and maximizes impact on beneficiaries. To this end, the implementer will be expected to support the development of county-specific work plans which target bottlenecks to improving CHT/DHT and health facility capacity for better health outcomes at the sub national level. The activity will strengthen local organizations for transitional leadership and make use of existing systems for ownership and sustainability.

Specific illustrative results are listed below for each Objective and Intermediate Result (IR) that the potential applicants/offerors must support per the stated timeline. The potential applicants/offerors may propose revised percentage achievements, outlined below, with sufficient justification explaining the rationale for the revised results. Direct implementation of GOL/MOH processes is not expected from the implementer; rather, it should support GOL counterparts through appropriate and targeted technical assistance to achieve the specific results listed herein. Targets and indicators for out-years will be developed after the first three months of the award when more accurate baselines, data measures and means of verification will be agreed upon in partnership with USAID and MOH.

Period of Performance

The period of performance of the LHESS activity is initially two base years with a possibility of 3 renewal years.

SPECIAL CONSIDERATIONS

A. OPERATING CONSTRAINTS

Given that this activity does not provide direct health services, if there are delays in payment of healthcare workers’ salaries, labor strikes, stock out of essential medicines, then the delivery of health services will be impacted and that will affect the quality-of-care improvement approaches, and therefore the ability of the implementer to provide technical assistance. Additionally, shifts in the government leadership based on the 2023 elections may lead to shifts in the MOH leadership, political/economic instability, GOL policies, and/or FARA priorities could be potential constraints for this activity.

B. COLLABORATION, LEARNING AND ADAPTATION

USAID seeks to promote learning across stakeholders involved in the implementation of this activity through Collaborating, Learning, and Adapting (CLA). Activity learning is intended to benefit all stakeholders.

CLA Objectives:

1. Generate Knowledge. The implementer will be expected to generate new knowledge and evidence around learning questions identified together with USAID and other stakeholders, as well as questions that may emerge during implementation. In filling these knowledge and evidence gaps, the implementer will provide reporting, data, analysis, and gather partners for inclusive reviews of the activity goals and results.

2. Share Knowledge. The implementer will be expected to increase knowledge sharing with stakeholders, including sub-awardees, local organizations, the private sector, national and local level MOH, sectoral experts, donors, regional and international organizations, and others through communities of practice to encourage more widespread learning across teams, mechanisms, and sectors. The implementer will convene forums to share knowledge and will also use existing forums as available. This activity will support the provision of case studies, lessons learned, success stories, and learning events to share among partners and stakeholders working in health systems strengthening. This includes working with USAID, PMI, GHSA, MOH, CSOs, domestic and foreign academia, and other partners to identify lessons learned from previous and ongoing sector wide programming, including the World Bank Funded Performance Based Financing and TA awardee.

3. Incorporate Agile and Adaptive Processes. The implementer will develop adaptive management and implementation processes to allow course correction to respond to unintended effects, changing/emerging realities, and priorities. Together with USAID/PMI/GHSA and MoH, the activity’s work plan, quarterly reports, and periodic progress review meetings will provide a forum for an adaptive approach to change course or make corrections based on lessons learned and evolving country context. The implementer will prioritize activities together with USAID, PMI, GHSA, and the MoH during work planning and review the prioritization during the quarterly reporting period. If circumstances arise, the activity can and will pivot to accommodate the situation, as long as the reprogramming does not hold the USG to incurring additional costs unless otherwise directed by the Contracting/Agreement Officer.

4. Guiding principles. USAID suggests consideration of several guiding principles in developing activity approaches. Potential applicants/offerors may recommend modifying and/or expanding these principles.

● Promoting local leadership: As recognized in principles of aid effectiveness, local ownership, and leadership are critical to the success and sustainability of any development intervention. Programmatic approaches must place local actors in the position to shape and direct program inputs, building on their strengths and expanding their capacity to increase their effectiveness and sustainability. The approach to improving quality of healthcare under this award is based on this guiding principle.

● Appreciating and building on the positive, using local assets: It can be easy for development practitioners to get caught up in analyzing and treating problems.

Appreciative, asset-based approaches look for what works and what can be built upon.

They encourage individuals and communities to own the development process and focus on optimizing use of local resources, which may mitigate creation of dependency on outside resource flows. Considering the context of Liberia, the LHESS activity is intended to use local solutions implemented by local actors for capacity enhancement and subsequent transition to a locally led technical assistance approach.

C. USAID, USG, AND OTHER DONOR COORDINATION

The implementer will be expected to work in the 15 counties of Liberia, including the eight (8) counties supported by USAID directly through the G2G Partnership and seven (7) counties supported by the President’s Malaria Initiative. Select laboratories across the counties will be supported through the GHSA.

This activity will be required to coordinate with the World Bank’s implementing partner providing technical assistance in three counties, for a national approach to health systems strengthening. Based on historical technical assistance provided under previous USAID funded activities to Bong, Lofa, and Nimba counties, the type and level of effort of technical assistance (TA) may vary from other counties.

The activity will create linkages and synergies with other partners working across both service delivery support and health systems strengthening in the same geographic area including the FARA, Maternal and Child Survival Program (MCSP)-EMS, and Partnership for Advancing Community Health (PACS).

In the area of health financing, USAID is exploring opportunities to expand quality private sector provided services in Liberia. The LHESS implementer must coordinate with these future activities and be part of the wider community of practice in health financing to ensure sharing of lessons learned, new data and new ideas.

D. GEOGRAPHIC FOCUS

The implementer will be expected to co-locate with the Ministry of Health, including the various units at MOH Central in Monrovia as well as the required County Health Teams. This activity will reflect the geographic alignment of USAID’s G2G, PMI, MCH/FP, and GHSA investments.

County TA History

Bong FARA/G2G Partnership since 2011; MNHTA Accelerator support since 2021;

CHA

Lofa FARA/G2G Partnership since 2011; MNHTA Accelerator support since 2021;

CHA

Nimba FARA/G2G Partnership since 2011; MNHTA Accelerator support since 2021;

CHA

Grand Cape Mount

FARA/G2G Partnership since 2017

Grand Gedeh FARA/G2G Partnership since 2017

River Gee FARA/G2G Partnership since 2017; CHA

Grand Bassa G2G Partnership since 2021; PMI from 2019 -2022

Margibi G2G Partnership since 2021; PMI from 2019 -2022; MNHTA Accelerator support since 2021

Montserrado PMI since 2019

Maryland PMI since 2019

Grand Kru PMI since 2019; CHA

Bomi PMI since 2019

Sinoe New – PMI Scale-up; World Bank GFF/PBF

Rivercess New – PMI…