Notice of Funding Opportunity (NFO) Number: RFA

Transcription

1 Issue Date: April 25, 2017 Deadline for Questions/Clarifications: May 5, 2017 Closing Date: May 26, 2017 Closing Time: 09:00 a.m. Nepal time Subject: Notice of Funding Opportunity (NFO) Number: RFA Program Title: Health System Strengthening (HSS) Ladies/Gentlemen: The United States Agency for International Development (USAID) is seeking concept papers for a cooperative agreement from qualified U.S. and Non-U.S. organizations to fund a program entitled Health System Strengthening. Eligibility for this award is not restricted. See Section C of this NFO for eligibility requirements. Applicants will submit concept papers that respond to the objectives outlined in this NFO. USAID will then conduct a merit review of the concept papers. The organizations submitting the most highly rated concept papers will be invited to the oral presentation phase. Subject to the availability of funds an award will be made to that responsible applicant(s) whose application(s) best meets the objectives of this funding opportunity and the selection criteria contained herein. While one award is anticipated as a result of this NFO, USAID reserves the right to fund any or none of the applications submitted. For the purposes of this NFO the term "Grant" is synonymous with "Cooperative Agreement"; "Grantee" is synonymous with "Recipient"; and "Grant Officer" is synonymous with "Agreement Officer". Eligible organizations interested in submitting an application are encouraged to read this funding opportunity thoroughly to understand the type of program sought, application submission requirements and evaluation process. To be eligible for award, the applicant must provide all information as required in this NFO and meet eligibility standards in Section C of this NFO. This funding opportunity is posted on and may be amended. Potential applicants should regularly check the website to ensure they have the latest information pertaining to this notice of funding opportunity. Applicants will need to have available or download Adobe program to their computers in order to view and save the Adobe forms properly. It is the responsibility of the applicant to ensure that the entire NFO has been received from the internet in its entirety and USAID bears no

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3 TABLE OF CONTENTS Abbreviations and Acronyms 4 Section A Program Description 6 Section B Award Information 31 Section C Eligibility Information 33 Section D Application and Submission Information 36 Section E Application Review Information 42 Section F Federal Award and Administration Information 44 Section G Agency Contacts 52 Section H Other Information 53 3

4 ABREVIATIONS AND ACCROYNMS USED IN THIS NFO CB-IMNCI Community Based Integrated Management of Neonatal and Childhood Illness CDCS CIP Country Development Cooperation Strategy Costed Implementation Plan DHIS-2 District Health Information Software 2 DHS DLIs DFID DO DoHS DPT3 elmis FCHV FY GAVI GESI GIS GIZ GON HC3 Demographic and Health Survey Disbursement Linked Indicators Department for International Development, UK Development Objective Department of Health Services Diphtheria, pertussis and tetanus vaccination Electronic Logistics Management Information System Female Community Health Volunteer Financial Year The Global Vaccine Alliance Gender Equality and Social Inclusion Geographic Information System Deutsche Gesellschaft für Internationale Zusammenarbeit Government of Nepal Health Communication Capacity Collaborative 4

5 HMIS H4L IR ISO JHPIEGO KOICA LMBIS MoFALD MoH NENAP NFHP I and II NFO NHSS NRs SWAp TABCUS UNICEF UNFPA VDC WHO Health Management Information System Health for Life Intermediate Result International Organization for Standardization Non-Profit Health organization affiliated with John Hopkins University Korea International Cooperation Agency Line Ministry Budgetary Information Systems Ministry of Federal Affairs and Local Development Ministry of Health Nepal s Every Newborn Action Plan Nepal Family Health Program I and II Notice of Funding Opportunity Nepal Health Sector Strategy Nepali Rupees Sector Wide Approach Transaction Accounting and Budget Control System United Nations Children's Fund United Nations Population Fund Village Development Committee World Health Organization 5

6 SECTION A: PROGRAM DESCRIPTION Overview USAID/Nepal anticipates awarding a 5-year Cooperative Agreement to improve health outcomes, particularly for the most marginalized and disadvantaged groups, by improving access to and quality of maternal, child and reproductive health services, with specific focus on newborn care. The focus will also be on strengthening data driven planning and governance of a decentralized health system, which in turn will increase utilization of equitable, accountable and quality health care services. This will be achieved through three objectives: Outcome 1: Improved access to and utilization of equitable healthcare services Outcome 2: Improved quality of health services Outcome 3: Improved health system governance, including within the context of decentralization and federalism 1. Background Since the end of the 10-year civil war in 2006, Nepal has been slowly moving towards building a more open and democratic society with a new Federal Constitution agreed in September Nepal is a landlocked country of about 28.5 million people and Nepali society is young (with a median age of 24 years) and is spread across challenging geographic terrain. Nepali society is also diverse with the 2011 census recognizing 125 social and ethnic groups 1. As of 2011, according to the World Bank, approximately 15 percent of the population still lived below the international poverty line of $1.90 per day 2. There is strong evidence that marginalized and disadvantaged groups suffer from multiple dimensions of poverty and social injustice and that discrimination of women is common across all social groups. Health Status Despite persistent poverty, human development indicators continue to show marked improvement. In 2015, Nepal had the fourth lowest Human Development score in the region, ahead of Pakistan, Afghanistan and India. 3 Also, in terms of life expectancy and education it ranked fourth, likely the result of the overall human development score being affected by Nepal s extremely low per capita income. Maternal health has seen remarkable improvements. Skilled attendance at birth has doubled between 2006 and 2011 and teenage pregnancy has fallen by 10 percent over the same time 1 Government of Nepal, Central Bureau of Statistics (2015) Nepal in Figures 2 World Bank (2011) Nepal: National Living Standards Survey 3 UN Human Development Report 6

7 period. 4 The coverage of antenatal care is 68 percent, with 60 percent of women receiving four or more visits, but postnatal care attendance is much lower. 5 The use of modern contraceptives increased rapidly from 26 percent in to 44 percent in 2006 and has remained constant between 2006 and Nepal also experienced changes in method mix and source of contraceptives. The share of voluntary surgical sterilizations decreased from two out of three users in 1996 to around one out of two users in During the same time of period, users accessing contraceptives from the public sector decreased from 79 percent to 69 percent, indicating the increasing contribution of private facilities, medical pharmacies and nongovernmental organizations in providing family planning services. Concomitantly, the total fertility rate decreased from 4.6 in 1996 to 2.6 in An important factor influencing both contraceptive use and fertility is male migration. In 2011, close to one-third of women aged years reported that their husbands were out of country for employment. 7 When the contraceptive prevalence rate is estimated only for those women who are currently living with their husbands, it increases from 43 percent of all women to 62 percent in Further analysis showed that despite no change in the contraceptive prevalence rate between 2006 and 2011, the observed decline in the total fertility rate during the same period could also be attributed to spousal separation. 8 Based on analysis of data on low contraceptive prevalence or high unmet need, the sub-groups of population most in need of family planning services are: adolescents, postpartum mothers, Muslim and Dalit women, migrants, and those living in remote rural areas. Child mortality fell from 56 to 38 deaths per 1,000 live births between 2009 and and the number of children fully immunized remains above 80 percent. Neonatal mortality has declined at a slower pace than infant and child mortality. Neonatal mortality currently stands at 33 neonatal deaths per 1,000 live births in 2011 and 23 per 1,000 live births in Neonatal death is now a larger proportion of under-five deaths and has increased from 42 percent of underfive deaths to 61 percent in To further reduce preventable child deaths, the country must prioritize and focus on newborn survival. In Nepal, an estimated 12,975 of newborn deaths occurred in The primary cause of newborn death was pre-term complications (31%), followed by birth asphyxia or birth trauma (23%), followed by infections (sepsis, tetanus, 4 Ministry of Health, New ERA, Macro International Inc (2011) Nepal Demographic and Health Survey 5 UNICEF Nepal (2014) Multiple Indicator Cluster Survey 6 Ministry of Health, New ERA, Macro International Inc. (1996, 2006, 2011) Nepal Demographic Health Surveys 7 Ministry of Health, New ERA, Macro International Inc. (2011) Nepal Demographic Health Surveys 8 Khanal, M., Shrestha, D, Pant P, Mehata S (2013) Impact of Male Migration on Contraceptive Use, Unmet Need and Fertility in Nepal, Further Analysis of 2011 Nepal Demographic Health Survey 9 UNICEF Nepal (2014) Multiple Indicator Cluster Survey 10 UNICEF Nepal (2014) Multiple Indicator Cluster Survey Ministry of Health, New ERA, Macro International Inc. (2011) Nepal Demographic Health Surveys 7

8 pertussis, and other newborn infections, 19%) 11. Inequalities in health outcomes persist, with child mortality for the poorest wealth quintile more than double that of the richest, at 57 and 22 deaths per 1,000 live births respectively. The gap between the richest and poorest wealth quintiles for immunization (DPT3 and measles) and vitamin A, both provided as an outreach service, has narrowed, whereas inequalities in institutional delivery are still relatively high. Inequalities in relation to caste, ethnicity, religion and geographical areas, are even more stark. In 2011, 64 percent of Brahmin/Chhetri women had 4 antenatal care visits, 40 percent of Dalit women, 35 percent of Muslim women and only 32 percent for all women living in rural areas 12. Health System Status The Government health sector is managed by the Ministry of Health, with the delivery of services led by the Department of Health Services through a highly centralized system, in particular for planning and budgeting. While there has been a decrease in the proportion of the Nepal national budget allocated to health, from 6.29 percent in FY 2005/06, compared to 5.42 percent in FY 2014/15, there has been an increase in real terms from NRs 7.6 billion in FY 2005/6 to NRs 33.5 billion in FY 2014/15, respectively. The Ministry of Health s per capita spending was $39 in 2014, which is on par with what all low income countries spend on health, but this is still extremely low and not sufficient to cover the health care needs of the country and it is for example, less than half the per capita expenditure spent in India. Health Financing Out-of-pocket expenditure is the largest source of financing for health in Nepal, followed by government funds. Out-of-pocket (OOP) expenditure arises when the general public pays for services and the payment goes directly to health providers and pharmacies. Out-of-pocket expenditure in general is considered the most regressive way of funding health services and in 2010, the World Health Organization recommended 13 that countries should keep the proportion of out-of-pocket payment to less than 20 percent of total health expenditures. Out-of-pocket expenditures disproportionately affect the poor, incurring catastrophic costs that often push people into poverty. This is based on the correlation between OOPS and the percentage of households that fall into poverty. In Nepal, in 2009, out-of-pocket expenditure was approximately 47.7 percent of total health expenditure (WHO). 14 The second largest source of total health expenditure is from the Government of Nepal (21 11 Nepal s Every Newborn Action Plan, Ministry of Health, New ERA, Macro International Inc. (2011) Nepal Demographic Health Surveys 13 World Health Organization(2010) World Health Report. Health Systems Financing - the Path to Universal Coverage., p 52, Ministry of Health Nepal (2009) National Health Accounts, 2012 data from World Bank, 8

9 percent), followed by international donors (18 percent) 15. Government funds are allocated to public providers to fund inputs in advance, including operational costs, based on last year s budget and adjusted for inflation. This mechanism does not directly link funding received with the performance of health facilities. The Ministry of Health has introduced a set of activities that reimburse providers for treatments, including, for example, safe delivery, uterine prolapse management and voluntary sterilization. Cash transfers are also made to patients to compensate them for transport costs or to subsidize a specific activity such as nutritional support for tuberculosis patients. Allocative and administrative inefficiencies exist: a health facility may receive funding for uterine prolapse based on treatments, while at the same time receiving line item budget funds to meet operational costs for this service. In addition, line item budgeting and vertical programming means that every family health and child health program forecasts and budgets for the money needed for fuel for transportation costs for their own program at the district level. Government Health Services Health services are delivered through a network of health facilities distributed all over the country and in 2014 included more than 3,500 health posts, 200 primary health care centers, 65 district hospitals, 10 zonal, sub-regional and regional hospitals and 8 central hospitals. Approximately 50,000 female community health volunteers act as the primary link between communities and the health facility and support the delivery of outreach services. The health workforce represents about a third of the total civil service in Nepal and is administratively heavy, with 38 percent of the work force comprising management and support workers, while doctors account for 9 percent, nurses 13 percent and paramedics 18 percent. Based on 2012 data and the 2011 census, Nepal has 0.67 doctors and nurses per 1,000 populations, which is less than a third of the WHO recommendation of 2.3 doctors, nurses and midwives per 1,000 population 16. A package of basic health care services is available for free at all levels of health facilities in the public sector. The basic package includes a comprehensive set of preventative, promotive, curative, rehabilitative, and Ayurvedic services accompanied by a free drug list, access to which is considered a fundamental right guaranteed by the Nepal Constitution. Selected services that are beyond the package of basic health services are covered by other social health protection arrangements such as demand side financing schemes or social health insurance. The maternity incentive scheme which provides free delivery care, for example, now includes an incentive for four antenatal care visits and free care of the sick newborn. Some curative services at hospitals are also free for certain groups, such as Dalits and the poor, but accessing benefits is complicated and has hidden costs. The Government has established social service units at zonal or regional hospitals with high caseloads. These units help poor 15 Ibid 16 World Health Organization (2014) Human Resources for Health. Country Profile - Nepal 9

10 people navigate a complicated tertiary hospital setting and ensure they have access to free care. The Nepal Government is rolling out a social health insurance program that covers the cost of tertiary care for people who buy into the insurance scheme. The service is available in three districts with a plan to expand to 10 districts in 2016/17 and then to expand nationwide to eventually include subsidized, means-tested enrollment for poorer populations. Women continue to face challenges in seeking care. The distance to reach a health facility and the cost of treatment, whether actual or perceived, is still critical barriers to seeking care. For example, those stating "distance to a health facility" as a barrier to using health services has increased from 41 percent to 47 percent from 2006 to 2011 and those who stated that "getting money for treatment" as a barrier to accessing care has increased from 39 percent to 47 percent over the same time period 17. The perceived cost of care or treatment may in fact be justified as the 2015 Health Facility Survey indicates that of the three basic health services, family planning, antenatal care and sick child (acute respiratory infections, diarrhea, malnutrition) that should be free of cost, a greater proportion of family planning clients received free services during the day of the survey, compared to antenatal care and those bringing sick children. People are least likely to receive these services (family planning, antenatal care and sick child care) free of cost at district hospitals, with only 25% of clients receiving free services for a sick child 18. More people are using health facilities in Nepal than a generation ago, but public sector health facilities are not yet ready to provide the full range of services that are mandated. For example, only a fourth of district hospitals and 18 percent of primary health care centers have all the basic equipment needed to deliver the full range of services. Sixty-four percent of district hospitals have running water; half of all facilities have regular electricity; one-fifth of facilities have communication equipment and only one out of ten facilities have a computer with internet. 19 Clinical skills of health staff are also poor. According to the Health Facility Survey, only 2 percent of health workers checked sick children for all three major danger signs (ability to eat or drink anything, vomiting and convulsions) during consultations. 20 A birthing center assessment illustrated the low use of the partograph in labor; less than 20 percent of health workers were able to correctly resuscitate a newborn and over 40 percent of health workers were not washing their hands with soap and water before vaginal examinations. 21 Yet, more than two-thirds of health facilities reported to have both routine staff training and personnel supervision. Private Health Services 17 Ministry of Health, New ERA, Macro International Inc. (2011) Nepal Demographic Health Surveys 18 Ministry of Health, New Era, Macro International (2015) Health Facility Report 19 Ibid 20 Ibid 21 Ministry of Health, Family Health Division (2014) Results from Assessing Birthing Centers in Nepal 10

11 More people than before are seeking care but recently, many are choosing to use private providers. In 2014, of those who had a sick child, half sought treatment from private providers. 22 The private sector has expanded rapidly from 16 private hospitals in 1990, to 301 in 2014 and it is estimated that 60 percent of hospital beds are now provided by the private sector. 23 Most of the private hospitals are in Kathmandu, but in rural areas, people are increasingly using private pharmacies for medical consultations. The expansion of the private sector has been haphazard with licenses for private facilities provided by different levels of the Ministry of Health. Quality of services is not optimal and uniform across all facilities. Many private hospitals do fulfill the Government of Nepal s requirement to set aside 10 percent of all beds for the poor, yet, how this set-aside is being always utilized remains unclear, and in some cases more than 10 percent of beds are being utilized by the poor. In general there is mistrust and misunderstanding between the public and private sectors. However, the Ministry of Health has been working in different ways with the private-not-for profit sector since the 1950s and has a number of memoranda of understanding with private-not-for-profit organizations to provide technical support, services, or facility management. Health Governance and Decentralization The Government of Nepal developed the Health Sector Gender Equality and Social Inclusion Strategy 2009 to provide a framework for integrating GESI throughout the health sector and the Local Self Government Act 1999 mandates the representation of women, economically and historically disadvantaged groups, communities and adibasi janajatis in VDC and ward level development committees, and empowers district-, municipality-, and village-level districts to operate and manage health services and mobilize resources to better respond to local priorities and needs. So the systems for governance of the health sector are in place in Nepal; however, adherence varies widely. In , 82 percent of all health facilities had regular management meetings, but only half of management committees organized a social audit. 24 Health facilities have improved recording and reporting, with nearly all public health facilities (94 percent) compiling a record sheet for the health management information system. Although required to do so, only 27 percent of public facilities display these record sheets. 25 Focused and sustained support for evidence-based planning and budgeting, and engagement of the community in these processes can result in better governance of facilities and increases in health utilization. USAID/Nepal s involvement in local health planning and governance from Nepal Family Health Program I and II to Health for Life (H4L) is significant and has led to a valued reputation and a wealth of experience in this area. H4L, for example, has demonstrated 22 UNICEF Nepal (2014) Multiple Indicator Cluster Survey 23 Government of Nepal, Central Bureau of Statistics (2013) Census of Private Hospitals in Nepal 24 Ministry of Health, New Era, Macro International (2015) Health Facility Report 25 Ibid 11

12 that almost all local health facilities within the activity area can increase the range of health services available, upgrade quality, attract additional local resources, and involve communities, in particular marginalized groups. 26 However, there are structural issues that prevent better local management of health resources in Nepal. A predominantly centralized planning and budgeting process exists, which is driven by central health targets. This means that a District Public Health Office has approximately 300 fixed budget lines by which to deliver a series of activities that may or may not be relevant to the local health situation and with very little ability to tailor these programs to their local needs. At the same time, there are more local resources available for health than ever before, through the Ministry of Federal Affairs and Local Development (MoFALD), for example, and other sources. MoFALD channels block grants to district level bodies and earmarks 35 percent of these block grants to activities in the social sector, including health. The Ministry of Health also provides a small amount of resources to some districts to top up the block grant. Since 2010, a number of donors, including USAID s Nepal Family Health Program II ( ) and H4L, have worked in a small number of districts to support the integration of health into local planning processes and to help better spend these resources. USAID s new Public Financial Management Strengthening activity will work in districts to improve budget planning and execution. However, many local resources generated for health are often not spent in the most strategic way, or are not used to cover essential needs, such as operating, maintenance and transportation costs. In the absence of locally elected leaders, the leadership role in local bodies, such as the health facility operation and management committee (HFOMC), has been assigned to the Village Development Committee (VDC) secretary who is an employee of MoFALD and in most cases not from the same community. The VDC secretaries have very little incentive to be present at HFOMC meetings and respond to the concerns of the community as they report directly to MoFALD and are not accountable to the community. Elected representatives would have more incentive to listen to their voting constituency. Nepal s recently-approved Constitution introduces federalism and the creation of 7 semiautonomous states. Although the details and implications for health service delivery are not yet known, moving away from a highly centralized planning and budgeting system will be a priority. Given the uncertainties, challenges are likely to arise as the government adapts to a new management structure, including the potential for gaps in the delivery of healthcare services. The possibilities of the government not being able to provide health care services during this political transition (particularly to the most marginalized) cannot be ignored and this in turn may instigate violence and fuel further political instability. Therefore there is a need to support the Nepal Government through this decentralization process and ensure that the health system functions optimally and that people are able to access quality and equitable health care services without disruptions. 2. USAID Support to Nepal s Health Sector 26 H4L semi-annual and annual reports 12

13 USAID/Nepal has a long, successful and highly- regarded engagement in health. USAID/Nepal s key contributions over the past 25 years of engagement have been strengthening service delivery both at the health facility and in the community. The support to both the female community health volunteers and family planning has contributed to significant improvements in maternal and child health. USAID/Nepal has been at the forefront of designing innovative and wellevaluated service delivery pilots, which are then taken to scale in areas such as the distribution of vitamin A; the community treatment of acute respiratory infections and diarrhea, the distribution of chlorhexidine to prevent cord infections in newborns; and misoprostol distribution for the prevention of postpartum hemorrhage. USAID/Nepal has been the key bilateral donor in Nepal for supply chain management and has a strong reputation in evidence generation, from the evaluation of the pilots mentioned above to the support of the 5-year Demographic and Health Surveys. A summary of the current USAID health activities that are relevant to the new health systems strengthening activity are listed below: Health for Life (H4L) Health for Life (H4L) is USAID/Nepal s 5-year flagship health system strengthening program which will end in December H4L was designed to build upon the success of previous USAID/Nepal s previous health system strengthening activities, such as the Nepal Family Health activities I ( ) and II ( ). In particular, the community and service delivery interventions for maternal and child health, the quality improvement teams and better evidence based health planning. The activity was originally designed to operate in 14 districts of the Mid- Western and Western Regions with a budget of $18,000,000. H4L was expanded to cover 10 of the most earthquake affected districts and 4 additional demonstration districts to support the roll-out of the local Government s collaborative framework and the budget for H4L was increased to $27,900,000. Through the H4L activity, USAID/Nepal has supported the Government of Nepal in areas of health governance, evidence-based decision making, service quality improvement, capacity building of health workers, and the utilization of family planning and maternal, newborn, and child health services. H4L has made some impressive progress, and laid a good foundation for the future health system strengthening activities and the country s transition into a federal structure. H4L uses evidence based approach to targeting marginalized VDCs and have been successful in increasing access to health care services by the marginalized groups in their project districts. Suaahara II USAID/Nepal s Suaahara II activity is a 5-year ( ) $63,000,000 cooperative agreement that aims to improve the nutritional status of women and children in 40 districts of the Terai, Hills and Mountains, covering all regions of Nepal. Suaahara II supports the Government of Nepal in expanding health and nutrition services targeting mothers, children and families who fall within the 1000 days window (from pregnancy until a child reaches 24 months of age) and adolescent girls. Suaahara II assists the Government of Nepal in implementing the Multisector Nutrition Plan, with activities that focus on the health, nutrition, agriculture, WASH, and family planning factors that contribute to undernutrition. The new health system strengthening activity 13

14 will need to work closely with Suaahara II to strengthen the Nepal Government s maternal and child health nutrition-related services, in particular Community Based - Integrated Management of Newborn and Child Illness (CB-IMNCI) which is a package of activities to address major childhood illnesses such as pneumonia, diarrhea, measles, malaria, and undernutrition. The CB- IMNCI program includes essential care for the newborn, management of sick newborns, and activities to increase community participation and uptake of services. Suaahara II uses evidence based approaches to improving the health and nutrition status of women and children in the most marginalized and disadvantaged groups; engaging with men and other decision makers in families and communities to promote positive behavioural changes. Family Planning Service Strengthening Program USAID/Nepal s Family Planning Service Strengthening Program (FPSSP) (also commonly known as SIFPO - Support to International Family Planning Organizations) is a four-year ( ), $10,000,000 program that supports the Government of Nepal, the International Planned Parenthood Federation/Family Planning Association of Nepal, and Marie Stopes International/Sunaulo Parivar Nepal to deliver family planning services in 22 districts. The goal of FPSSP is to strengthen family planning services through both the Ministry of Health and the private sector. Activities include: service provision, including postpartum family planning through outreach clinics and health facilities; competency-based training for MOH health workers for long-acting methods and post-training follow up, coaching and mentoring; counseling training to improve interpersonal communication; communication through street drama, radio, and TV programs to encourage social behavior change; and working with districtlevel Government officials to improve technical and logistic support. The new health system strengthening activity will need to continue the important work begun by the SIFPO activities to further strengthen the Ministry of Health s (MoH s) family planning service delivery and outreach. Health Communication Capacity Collaborative (HC3) USAID/Nepal s Health Communication Capacity Collaborative (HC3) is a four-year ( ), $10,000,000 activity that focuses on family planning messages for youth, adolescents, migrants and marginalized and disadvantaged groups. HC3 works with the Ministry of Health s National Health Education Information Communication Centre (NHEICC) to design, develop and evaluate targeted social behavior change communication programs for family planning. HC3 works in 13 districts across Nepal and is designed to support the delivery of FPSSP. The national campaign Smart Couple launched in 2015 has become well-known and focuses on young, lowparity couples encouraging them to delay the next pregnancy. It is not expected that the new health system strengthening activity will be involved in national campaigns for family planning but could usefully build upon the HC3 activities with Government health workers on appropriate family planning counseling for example. Swachchhata USAID/Nepal s Swachchhata is a $4,790,000, 5-year ( ) health and hygiene activity working in 80 health posts in 5 districts of Nepal (Salyan, Rukum, Dolpa, Kalikot, Jajarkot). The 14

15 activity supports the construction or renovation of small-scale safe water and solid/medical waste management and maintenance systems; solar power supplies; and sanitation, hygiene and infection prevention in health facilities. It also supports health facility management committees on maintenance strategies for water and solar investments and is working with the health facility and the community on changing staff and client behaviors related to poor hygiene and sanitation. H4L is currently active in all Swachchhata s districts except Dolpa. With poor infection prevention practices across health facilities in Nepal, it will be important for the new health system strengthening activity to work closely with Swachchhata, showcasing good practices and encouraging non-swachchhata health facilities to invest in water and waste management and adopt better infection prevention practices. Global Health Supply Chain Program USAID s Global Health Supply Chain Program operates in Nepal as a 5-year ( ) $15,000,000 activity supporting the Department of Health Services to update their logistics management information system in 2000, service delivery points and to strengthen the capacity of the Logistics Management Division in forecasting and supply planning. The activity will also analyze issues related to the transportation and delivery of commodities but will not propose interventions in this area. The logistics management information system will be digitized starting with a pilot and then moving to the Mid-Western region, followed by an expansion to 2000, sites. The new health system strengthening activity is likely to focus in the same districts of the Mid-Western region and so will benefit from access to real-time data on drug and commodity supply and better management of district level stores. Fertility Awareness for Community Transformation (FACT) USAID s FACT activity is testing whether increased fertility awareness improves family planning use and whether expanded access to fertility awareness-based methods increases uptake of family planning and reduces unintended pregnancies. The intervention is in four districts, and will have research results available in Goal, Purpose, and Outcomes The health system strengthening activity will ensure better maternal, neonatal and child health and family planning services and in doing so, will assist Nepal in achieving the Sustainable Development Goals. The activity will contribute to USAID/Nepal s CDCS Development Objective 3 (DO 3): Increased Human Capital, will directly address the Intermediate Result (IR) 3.2: A Healthier and Well-nourished Population, and will contribute to (IR) 3.3: Social Sector Policy and Performance Improved. The purpose of the activity is to improve health outcomes, particularly for the most marginalized and disadvantaged groups, by improving access to and utilization of quality of maternal, child and reproductive health services, with specific focus on newborn care. The project will also strengthen data driven planning and governance of a decentralized health system, which in turn will increase access to equitable, accountable and quality health care services. Figure 1: Purpose, and Outcomes with Cross Cutting Issues 15

16 Development Hypothesis and Critical Assumptions The health of the general population has improved dramatically in Nepal and it is therefore no longer appropriate to just further the health status in Nepal by any means possible, but to build local capability to deliver health services. Essential health care services that are equitable, of high quality and delivered principally by the Government will assist in meeting the expectations that the Nepali people have of the state in providing key services, as enshrined in the new Constitution. Given that the health workforce represents about a third of the Nepal civil service, a workforce that is better equipped with the clinical tools of the trade and is administratively capable to plan, manage and monitor health programs, both transparently and with appropriate evidence, will increase both administrative and allocative efficiency. Formalizing public-private partnerships, if only incrementally, particularly in quality standards as part the new social health insurance program and in service areas that cannot be delivered by the government, for example, will encourage the Ministry of Health to move towards a role of steward and regulator of the entire health sector. Critical Assumptions - The assumptions that underpin the results are that they are treated as mutually reinforcing with the right balance between services, quality, and governance. These will lead to the achievement of the overall purpose: that appropriate capacity can be built leading to demonstrable outcomes; and that the move to a federal structure and the frequent transfer of government personnel will need to be acknowledged and taken into account, but will not fundamentally impede progress. A. Outcomes, Illustrative Activities, and Indicators 16

17 Outcome 1. Improved access to and utilization of healthcare services There continues to be a need to focus on sustaining improvements in the public sector, at the district hospitals, public health offices, primary health care centers, health posts, and in extending outreach in the community and with community volunteers. Basic health services at the primary level are free and have resulted in an increase in use, especially by the poor and marginalized groups. As outlined in the NHSS, the basic health care package should be streamlined depending upon the level of health facility, the population and geography. The implementation of the package should be accompanied by appropriate transparency measures. The primary mechanism in which a health facility can address geographic barriers is through strengthening outreach programs. Most health workers in a health post are mandated to provide some kind of outreach service but these services are not always implemented strategically - where there is greater need for example, or with the resources necessary to provide outreach services in remote areas. Also, there is an outstanding need to clarify who should be working in the community and what outreach services should be provided. For example, there are remote area guidelines for both safer motherhood and for the management of sick children which encourage task-shifting from higher to lower level cadres, including to Female Community Health Volunteers (FCHVs). The Nepal Health Sector Strategy (NHSS) however, advocates for the establishment of community health units with an associated increase in health workers, with FCHVs still playing a useful promotional role in those communities as well as having a broader role for the treatment of some illnesses in the more remote communities. Access to and utilization of health services has increased but progress has been uneven. Over the past five years, disparities among castes, ethnicities, and wealth quintiles have decreased in contraceptive use, childhood immunization, diarrheal disease control, and treatment for acute respiratory infection. However as demonstrated by NDHS 2011 women in the highest wealth quintile are almost three times as likely to receive delivery care from a skilled provider (92%) as women in the lowest wealth quintile (33%). Social and cultural barriers are more difficult to address and require good knowledge of the local population and their specific challenges in order to develop appropriate demand generation activities and training in provider attitudes and approaches to care, particularly when providing services to special groups like adolescents, postpartum mothers and survivors of gender-based violence. This includes strong GESI considerations to address and eliminate disparities for women and marginalized groups. Service delivery activities should be coordinated with demand generation activities. USAID s Suaahara, H4L and HC3 activities have all demonstrated success in disparities reduction for both service utilization and health seeking behavior, and a close working relationship with these activities will be critical. Client preferences in Nepal are changing, with private providers becoming more accessible and popular even in rural areas, with an increase in the use of small medical shops and pharmacies for care and treatment. The accuracy of diagnosis and the quality of service provision in these small outlets is not known and needs to be assessed and addressed if required.. Illustrative Indicators (not meant to be a comprehensive list) 17

18 Number and percent of health facilities providing all basic health services, disaggregated by the level of health facility. Number and percent of clients who received basic health services free of cost for tracer services (family planning, antenatal care, sick newborn care) disaggregated by sociodemographic groups Number and percent of service delivery sites providing family planning counseling and/or services Number and percent of institutional deliveries / births assisted by skilled birth attendants (disaggregated by age, wealth quintile, caste/ethnicity) Number of clients reached through outreach for tracer services (family planning, antenatal care, sick newborn care) disaggregated by age, income quintile, caste/ethnicity. Number of sick newborn infants receiving antibiotic treatment for infection (public and private facilities) disaggregated by wealth quintile, education level, caste/ethnicity. Number and percent of postpartum women accepting family planning disaggregated by age, wealth quintile, caste/ethnicity) Number and percent of health facilities electronically reporting to the health management information system Outcome 2. Improved quality of health services The lack of readiness of health facilities to be able to deliver quality services is becoming a critical impediment to further progress in the quality of the health system of Nepal. As noted above, only 25 percent of district hospitals and 18 percent of primary health care centers have all the basic equipment needed to deliver services. 27 Private sector facilities have similar limitations. To date, the approach to address quality standards has been piecemeal and crowded with development partners; there is little consensus or understanding of key terms such as quality assurance, licensing, and accreditation. Furthermore, the NHSS has an entire outcome on quality of care at the point of delivery, with activities that start from defining standards for each level of health facility right up to an independent body for accreditation. There are a number of tools including those developed by H4L that work with management committees of the different levels of facilities to assess, identify gaps, develop and implement actions plans. The need continues for quality improvement processes and better linkages to clinical mentoring and supervision. The majority of activities should be focused on the district level, but centers of excellence will be needed for the care of the sick newborns referred from lower level facilities. Partnering with tertiary level institutes like the Tribhuvan University Teaching Hospital, Kanti Children s Hospital or Dhulikhel Hospital for establishing quality and client -focused neonatal intensive care units at referral levels could be a useful strategy in this regard. There is a need to focus on the basics. At the moment, there is no agreed minimum standard of operations for all levels of facilities. Once standards are in place, it will be easier to identify gaps 27 Ministry of Health (2015) Health Facility Report 18

19 and measure progress against these standards at a district, regional or national level. These standards could be used as a prerequisite to enrolment for private facilities in the social health insurance, for example, or as the basis for another kind of service contract. Some large private hospitals in Kathmandu are already using the ISO standards for medical laboratories. Information on whether facilities achieved standards or not, could be made public and provide a ranking of performance for both public and private facilities. Minimum standards could also form the basis of social auditing - explaining to the public and users of the service how well their local facility is performing against standards. The development and implementation of standards alongside strengthening (improving the quality and availability of services at the facility level) of the basic package of health services will ensure the range of services are available and delivered in an integrated manner. Primary health care should be reinforced as the first point of contact for the majority of people s needs. A key element of strong primary health care system is ensuring primary care is the entry point into the health system. The advantages of this approach is that it encourages the first point of contact to be as competent as possible, it strengthens and formalizes referral practices, encouraging more formal pathways from the community to primary to secondary/tertiary care. It also means that the health facility will develop a sustained relationship with their catchment population, empower the local population and encourage them to demand better services from their local health care provider. A gate-keeping function will only be successful however, if health facilities are functional and ready to provide services. Illustrative Indicators (not meant to be a comprehensive list) Number and percent of health facilities meeting minimum standards of quality of care at point of delivery (public and private facilities) Number and percentage of health workers complying with service delivery standard protocols for tracer services (antenatal care, family planning, sick child treatment) Number and percentage of health workers trained and available for family planning services Number and percent of hospital based maternal and perinatal deaths reviewed and action plan implemented. Number and percent of health facilities using partograms and post natal checks Number of supportive supervision visits Number and percentage of health facilities meeting the national health care waste management guidelines Number and percent of health facilities with functional referral systems Patient satisfaction of the quality of services improved disaggregated by age, wealth quintile, education level, caste/ethnicity) Outcome 3. Improved health system governance, including within the context of decentralization and federalism USAID/Nepal s involvement in local health planning and governance from Nepal Family Health Program I and II to H4L is significant and has led to a valued reputation and a wealth of experience in this area. Health governance and decentralization is a key outcome in the NHSS 19

20 giving further visibility to this area. There is a need to plan for two scenarios: The first, in preparation for federalism, with the structures and functions of the Ministry of Health as they currently exist, incrementally increasing more decentralized resources and flexibility in budgeting. The second scenario would be with the federal structures in place and actively working with the new structures to plan, budget, and deliver. The district (or municipality where appropriate, or the appropriate local unit after Federalism) needs to be considered as the local unit of planning and the approach to planning, budgeting and service delivery should cover all Municipal/Village Development Committees. There is an expectation that if planning is done appropriately, based on data, geography and knowledge of health facility readiness, then the activities planned by the district offices, the hospital and each health facility will be different. The activity should foster a strategic approach to health service delivery moving away from the existing centralized and blanket approach to need-based resource allocation and delivery, including supporting the development, implementation and monitoring of multiyear local plans to help ensure strategic long-term planning and accountability. Given the centralized nature of existing planning processes, engagement is needed at all levels of the annual work plan and budgeting process - center, district, local. There are a number of information tools that are available at the district level to be used in local planning and to encourage a more evidence-based culture which include: the electronic annual work plan and budget; TABUCS/LMBIS for the analysis of expenditure; HMIS launched in the DHIS-2 platform for disaggregated health utilization data and the elmis. Consideration needs to be given to what extent lower-level facilities could report health management information system data electronically and electronic patient record systems could be developed. The activity should work closely with the USAID Public Financial Management Strengthening activity and the Procurement and Supply Management (PSM) activity at the district level. The planning and budgeting process cannot be separated from the work on service delivery and quality, and transparency needs to be encouraged at all levels - to display open hours, citizen charters, information on free services, costs of services if not free, and incentive schemes available. H4L s work on engaging the community in the management of local health facilities and in generating resources for health has been critical. A more strategic approach is needed for engagement of women and excluded groups in Health Facility Operations Management Committees and other group structures, to increase knowledge and confidence in engaging in decision-making. Rotation among women and excluded groups is needed for leadership positions, as well as encouraging of active peer support and sharing of experience across Village Development Committees and even districts. Illustrative Indicators (not meant to be a comprehensive list) Percent of Ministry of Health district budget disbursed and spent Percent of total local government budget allocated and spent on health activities Number of districts submitting approved annual plans to the Department of Health Services within the specified time Number and percent of district (public) health offices, hospitals and health facilities demonstrating core competencies in analysis, and utilization of health information for health 20

21 sector planning and management Number and percent of districts with functional health coordination committees Percent of civil society organizations and community management entities engaged in public expenditure tracking. 4. Cross-Cutting Priorities: Private Sector and Evidence Generation The activity should look for opportunities to engage the private sector and to generate and use evidence across all three objectives. Engagement with the private sector may at first be opportunistic, and small-scale, and benefit from implementing inventive ways for bringing public and private sector leaders in health together to share ideas about possible areas for collaboration. This engagement should look for areas to further develop existing and trusted partnerships, such as with the existing service contracts or with the social health insurance scheme that has empaneled private providers. The NHSS has a cautious approach to public-private engagement indicating that over the next five years develop strategic initiatives that are mutually beneficial to both state and non-state actors. There are only two output-level activities in the NHSS that directly involve the private sector and include establishing strategic coordination mechanisms with the private sector in infrastructure and improve the capacity of district hospitals to deliver specialized services in partnership with public and private academic institutions. USAID has a reputation as the knowledge donor, consistently supporting the delivery of highquality evidence products, including service delivery pilots which are then taken to scale such as vitamin A distribution, misoprostol and chlorhexidine. In keeping with this tradition, some implementation researches may also be pursued within this activity, particularly around improving quality of care. The NHSS has an entire outcome on the improved availability and use of evidence in decisionmaking at all levels. Data availability is good with a range of information systems that are becoming more streamlined. Many systems are still paper-based and where connectivity is possible, using innovative IT and mobile-based technologies at lower level facilities, should be pursued. Implementation support is still needed for these information systems, in particular the health management information system (HMIS). But the key challenge across all levels is how to get health care providers and health care managers to use regular data and research in their everyday work and planning. The use of health data for decision-making in this activity will be primarily, but not exclusively, promoted to ensure priority health problems in local populations are appropriately identified and addressed systematically. 5. Target Population and Geographic Focus The activity will strengthen national systems and national processes, supplemented with a focus on selected priority districts with activities across the entire district. In line with MOH policy, the activity should work across the entire district and respond to variations in sub-district (VDC) health status needs, identifying, prioritizing and addressing the unique needs of the most 21

22 marginalised and vulnerable groups in the communities. The districts will be agreed upon by the MOH and USAID before the final award of this activity and will be selected based on an intersection of the following criteria: USAID s Country Development Cooperation Strategy geographical focus Previous H4L core activities Highest need as measured by the human development index values, HMIS and LMIS data High levels of marginalized populations Other USAID activities that influence health outcomes, for maximum impact and influence Minimized duplication with other donor health activities Clustering of selected districts to ensure cost-effectiveness. The primary target population are women of reproductive age, expectant and postpartum mothers, under five children, newborns, disadvantaged populations, and men and youth for family planning. The activity will directly support the Ministry of Health, the Department of Health Services, the Ministry of Federal Affairs and Local Development, and other relevant government institutions. At the subnational level, active collaboration with District (Public) Health Office, District Development Committees, Village Development Committees, hospitals and hospital development boards, health facilities and the health facility operation, and management committees, community health workers, and community health units, and other relevant institutions will be fostered. 6. Guiding Principles Applicants should describe how their technical and management approaches incorporate the following principles. Country Ownership, Capacity and Country Led Plans Nepal is a mature SWAp environment and all activities need to demonstrate that they contribute towards the NHSS, have buy-in of key government counterparts and build country capacity. USAID works in close collaboration with the Ministry of Health to design health activities, and engages with the Ministry of Health on a regular basis in donor forums and technical working groups. The activity will be an active partner of Government counterparts and will follow protocols and regulations, such as per diem rates, as set out by the Government of Nepal. The desirable level of engagement with the districts is that of a solid, functional partnership, driven by results. The activity will need to show how this will be attained based on common vision on what is to be achieved, the right combination of mentoring, tools, systems and processes and the drivers required to achieve this. At early stages of implementation the activity will develop a model for addressing sustainability across all objectives, as an example for other implementing partners, and as agreed with the Ministry of Health. At its start-up the activity must develop and implement a Sustainability Plan and Exit Strategy with a vision to leave processes, products, and expertise that are positioned for longevity beyond the life of the project. 22

23 This must be updated periodically as part of the Annual Work Plan development process and reported against in every Annual Report and in the Final project report using indicators and targets identified in the project Monitoring and Evaluation Plan. Strengthening Health Systems The activity will principally strengthen the public health system, its relationship with the private sector and its engagement with citizens and communities, as users of health services. The activity will need to demonstrate approaches that progressively improve and build the capacity of the health system over time by using existing structures and tools and piloting interventions that facilitate better efficiency and reduce the pervasive inequity in health outcomes among marginalized groups. It is important that the activity keeps its primary focus on building capacity at sub-national levels but district management cannot be de-linked from national systems, which are essential for the delivery of quality health services. Currently, many facilities lack adequate medicines, supplies and infrastructure which can only be tackled by engaging in central mechanisms. There are wellmanaged public facilities and poorly managed facilities, which indicate that governance will continue to be a key theme. At the start and over the course of the activity, select discrete activities, such as work with tertiary hospitals on sick newborn care may be identified, in coordination with the Ministry of Health and USAID, at the central level. Strategic Partnership and Coordination There are a number of donors and implementing partners who contribute to the health sector. The Ministry of Health requires that partners share information about activities and ensure that there is no overlap. As part of this effort, the activity will need to demonstrate where it is collaborating with other partners, not just to reduce duplication, but to pursue a joint understanding of emerging issues, best practices, and therefore ongoing adjustments to activities required by all partners. The activity will participate in appropriate coordination mechanisms at both central and sub-national level. USAID/Nepal has a number of other activities across multiple sectors- health activity as well as non-health activities that influence health outcomes like education and food security that will be active in the same districts and complementarity of activities should be identified early in the activity implementation. Flexibility and Integration in Programming Health systems are complex and change is not always linear or attributed to one intervention. The activity, therefore, will need to be adaptive and flexible. The monitoring, evaluation and learning section below describes in more detail possible approaches to adaptive programming. The activity will strengthen MNCH/FP services with a strong focus on the newborn. However, integrated service delivery is critical, ensuring that health providers are able to address the health needs of clients in a holistic manner so that services are not disjointed. The activity should implement an integrated service delivery approach across the entire district that also responds to variations in sub-district (VDC) health utilization and health needs, especially among marginalized populations. The level of effort, therefore, within each district will vary at different levels of the health system based on district-specific needs and to complement activities by other 23

24 partners. Thus, the activity will define the level of effort for each district and for each VDC that will lead to the rapid expansion of quality services. Conflict sensitivity and do no harm: Ensure that project activities are maximizing positive and constructive dynamics in the context and communities in which they operate, and not exacerbating negative or destructive dynamics. A conflict sensitive approach reflects understanding of the context in which the project will operate; the interaction between the proposed intervention and that context; and innovative thinking for avoiding negative impacts and maximizing positive ones. The innovative thinking should inform and be reflected in adaptive management decisions. For more information see Annex 5. Gender and Social Inclusion Gender equality and social inclusion (GESI) is an integral part of all of USAID/Nepal's work. There is a high and pervasive disparity in health outcomes by wealth, gender, caste and ethnicity, disability and geographic location in Nepal. The activity will need to strongly consider GESI issues when designing the technical approach; and to analyze the key exclusion issues in service delivery and how they will be minimized and monitored or improved health outcomes will not be achieved. USAID/Nepal's GESI analysis for this activity can be found in Annex 3. The USAID Gender Equality and Female Empowerment Policy can be found at Gender integration is a mandatory consideration in all USAID programming. Applicants are required to explicitly ask how gender issues such as identifying and understanding the causes of gender inequalities; differences in roles, responsibilities, and needs of men and women; and the relationships between men and women, within the same sex, and between older and younger men and women are linked to health care utilization and how gender issues will be integrated into all program components. Likewise, applicants must articulate how program activities will ensure equal opportunities for historically marginalized populations in Nepal s diverse society. Social exclusion, including but not limited to that experienced by women, is a defining feature of Nepal s political, economic and social fabric, and a central deterrent to the broad-based, inclusive development that the Mission s CDCS seeks to promote and support. Environmental Compliance The Foreign Assistance Act of 1961, as amended, Section 117 requires that the impact of USAID s activities on the environment be considered and that USAID include environmental sustainability as a central consideration in designing and carrying out its development programs. This mandate is codified in Federal Regulations (22 CFR 216) and in USAID s Automated Directives System (ADS) Parts g and 204 ( which, in part, require that the potential environmental impacts of USAID-financed activities are identified prior to a final decision to proceed and that appropriate environmental safeguards are adopted for all activities. The applicant must comply with host country environmental regulations unless otherwise 24

25 directed in writing by In case of conflict between host country and USAID regulations, the latter shall govern. No activity funded under this contract will be implemented unless an environmental threshold determination, as defined by 22 CFR 216, has been reached for that activity, as documented in a Initial Environmental Examination (IEE) duly reviewed and signed by the Mission Environmental Officer (MEO) and Bureau Environmental Officer (BEO). As part of its initial Work Plan, and all Annual Work Plans thereafter, the applicant, in collaboration with the USAID Agreement Officer s Representative and Mission Environmental Officer or Bureau Environmental Officer, as appropriate, shall review all ongoing and planned activities under this contract to determine if they are within the scope of the approved Regulation 216 environmental documentation. If the applicant plans any new activities outside the scope of the approved Regulation 216 environmental documentation, it shall prepare an amendment to the documentation for USAID review and approval. No such new activities shall be undertaken prior to receiving written USAID approval of environmental documentation amendments. Any ongoing activities found to be outside the scope of the approved Regulation 216 environmental documentation shall be halted until an amendment to the documentation is submitted and written approval is received from In addition, starting Oct. 1, 2016 climate risk management (CRM) is required for all new activities and activities. CRM entails using climate information and regional and technical expertise to assess and address the risk that climate change poses to USAID activities and activities and their ability to achieve the intended objectives. The Request for Categorical Exclusion (RCE) on environmental impact analysis is provided in Annex 4 which also incorporates climate risk considerations. Monitoring, Evaluation, and Learning (MEL) The activity must develop dynamic monitoring, evaluation and learning practices which provide opportunities for periods of intensive analysis, reflection and evaluation alongside regular activity monitoring. The activity should build upon the emerging work on adaptive management and flexible programming which encourages better use of evidence, and the ongoing generation and use of evidence, for performance and shifts the focus to activity outcomes instead of activities. The monitoring, evaluation and learning plan must include a strategy for data collection, analysis and for ensuring data quality. The activity should build on and strengthen existing systems, and strengthen local and national capacity to use data for decision making and promote accountability. The approach for building the capacity of local and national partners and strengthening existing systems should be clearly articulated. The use of GIS technology and geographic data is increasingly important to USAID s effort to 25

26 geographically target aid investments and effectively report on the scope and impact of the Mission s investments. The activity must consider the use of GIS and other technologies to map activities, to contribute to other central repositories and to overlay key data sets on health, in line with USAID Nepal s standards. Monitoring: Performance monitoring should be established to track outcomes. Output indicators that will lead to the achievement of the outcomes must be proposed and indicators at this level will need to be flexible. Adaptive management means that activities and outputs will change over the life of the activity based on emerging context and needs. At this level, no single indicator will capture the desired change. Applicants might want to consider output level indicators that are a combination of indicators and situations. This information should be used to make management decisions and allocate resources and to communicate achievements or failures. The data should comply with Open Data requirements and support better donor transparency and coordination on data collection, sharing, and analysis. When selecting indicators, the activity should be familiar with the standard USAID indicators, the NHSS results framework and those collected in the Demographic and Health Surveys and the Nepal Health Facility Survey. A Performance Indicator Reference Sheet (PIRS) is required for all indicators and should be complete prior to data collection to ensure the indicator and its data collection methodology is clearly defined. The indicator data must be reported to USAID using Aid Tracker Plus System at a frequency defined in the PIRS or as agreed in the activity level MEL plan. The illustrative indicators provided in this NFO are intended to serve as examples and the activity should propose other indicators if they would better measure the results of the proposed interventions. The activity must plan to collect, at a minimum, baseline/midterm/end line data for indicators for which there is no information. The MEL plan should include indicators or proxy indicators to track levels of social inclusion. Per USAID/Nepal policy, all person-level indicators for which data are collected and reported (either through routine monitoring, semi-annual/annual progress reports, evaluations or assessments) should be disaggregated by sex, age, and caste/ethnicity. The caste/ethnicity disaggregation should be, at a minimum, by the following six categories: Dalit, Muslim, Brahmin/Chhetri, Newar, Janajati, and other. Data should be disaggregated at the unit where the activity is implemented, by health facility, VDC and districts levels, as appropriate. For the purposes of this activity further disaggregation may be appropriate and will be agreed upon in the approved MEL Plan. Evaluation: USAID/Nepal plans to contract and manage a third-party firm to conduct an independent mid-term and/or final evaluation of the activity to understand whether the activity is on-track to meet its proposed outcomes. The activity should plan periodic and relevant internal evaluations. Learning: The activity should propose a learning agenda and learning plan in collaboration with the Government and other key partners which includes plans to identify and fill knowledge gaps, collaborate with relevant stakeholders, improve activity and government health service effectiveness and to share results. 7. Strategic Frameworks and Partnerships 26

27 Policy Frameworks The activity s overall strategic approach should be guided by a number of frameworks and policy documents developed by the Government of Nepal and the United States Government and should complement the goals expressed in each: Nepal Health Sector Strategy, (NHSS) The Ministry of Health s 5-year NHSS will be the key guiding document for the next 5-years. It has key outcomes in: (i) infrastructure, human resources, procurement and supply chain; (ii) quality of care at the point of delivery; (iii) equitable utilization of health services; (iv) decentralized planning and budgeting; (v) sector management and governance; (vi) health sector financing; (vii) healthy lifestyles and environment; (viii) management of public health emergencies and (ix) evidence in decision making processes. It outlines the path to universal health coverage through: the provision of basic health services that are provided free of charge and services beyond the basic health package at affordable cost through targeted subsidies and various social health protection schemes. Nepal Health Sector Strategy Results Framework, (NHSS) There are ambitious targets to meet by the end of the NHSS which are relevant to the new activity and include: the neonatal mortality rate reduced to 17.5 per 1,000 live births and fertility rate to 2.1, both with targets for income quintiles and geography; a reduction in out-of-pocket expenditure by 20 percent; 100% clients receive basic health services free of cost for tracer services (antenatal care, sick child treatment, family planning); 70% of institutional deliveries and 76% of demand satisfied for family planning, both with targets for income quintiles, geography and caste/ethnicity; 100% of health facilities providing all basic health services; 90% of health facilities meeting minimum standards of quality of care at point of delivery and 90% of health workers complying service standard protocols for tracer services, both with targets for the private sector; 10% of district development fund allocated for health and 5% of district budget is flexible; 100% of districts receiving budget based on identified needs and output criteria and 100% of health facilities electronically reporting to national health reporting systems, with targets for the private sector. Nepal s Every Newborn Action Plan (NENAP) The NENAP is aligned with the NHSS and has the same outcomes but is tailored to newborn care. Given that improvements in newborn health have stalled, the NENAP and its associated implementation plan, are the guiding documents for activities in this area. The NENAP focuses on the implementation of the key evidence-based maternal and newborn interventions surrounding 24 hours of labor, birth and the first few hours of life as proposed by the Newborn Lancet Series. It proposes that any new maternal and newborn interventions are integrated into existing facility and community-based programs. Costed Implementation Plan for Family Planning. (CIP) As part of its commitment to Family Planning , the Nepal Government developed a CIP to identify barriers to 28 Family Planning 2020 is a global partnership that supports the rights of women and girls to decide, freely, and for themselves, whether, when, and how many children they want to have. 27

28 accessing family planning services, especially for adolescents and youth, those living in rural areas, migrants and other vulnerable or marginalized groups. The service delivery strategies are to broaden the range of modern contraceptives available at different levels of the health care system, to increase access to quality family planning information and services and to engage in a range of communications and media activities to raise awareness of family planning among populations with a high unmet need for modern contraception. Quality Assurance in Health Care Services This policy aims to integrate all the activities that exist for improving quality and to ensure that a quality assurance system is in place. Yet the policy does not provide any guidance on how a quality assurance system should be established or function. Local Self-Government Act Provides the institutional framework through which the Government s decentralization policy is articulated. It stipulates that three sectors (health, education, agriculture) should be officially devolved. In practice, however, sector devolution has not been implemented in a meaningful way and the three sectors remain largely under the control of central line ministries with the district authorities simply being used for a banking function for the disbursement of sector funding to local level line agencies. In 2014, with support of USAID s H4L activity a collaborative framework between the Ministry of Health and the Ministry Federal Affairs and Local Development was ratified and implemented in 6 districts. The planning process results in an evidence based annual health plan, which serves as the guiding document for all health-related activities. Vision for Health System Strengthening U.S. Government sets out the global priorities for health system strengthening, with all USAID work contributing to achieve four strategic outcomes: financial protection; essential services; population coverage, and responsiveness. Many of the indicators set out in the vision are also found in the NHSS and include: reducing out-of-pocket expenditures; advancing the essential health services package and ensuring equity in access to skilled birth attendance, for example. Partnerships and Approaches Sector Wide Approach (SWAp). The NHSS is the strategic document to guide the third SWAp in health. All major donors and implementing partners adhere to the key principles of the SWAp - of aligning behind a national strategy and results framework and moving towards more use of country systems. Not all donors are able to provide resources through the Ministry of Health s budget but ensure that externally financed activities contribute to NHSS results and build the capability of the Nepal health system. The World Bank, the German and British governments and GAVI provide sector budget support to the SWAp through regular payments based on the verification of activities. USAID/Nepal also provides a small amount of sector budget support earmarked to agreed activities under different Divisions of the Department of Health Service. For the first time in this SWAp, the sector budget support donors will also provide annual payments once agreed targets have been met - commonly referred to as disbursement linked indicators (DLIs). The disbursement linked indicators may drive Ministry of Health s investments in certain areas and 28

29 the new health system strengthening activity may be able to contribute to the delivery of DLIs in the roll-out and use of the electronic annual work plan and budget, the electronic accounting system, the digitized health information system and the proposed citizen feedback pilots. The UN partners continue to work in their mandated areas. The new health system strengthening activity will need to work closely with UNFPA in family planning services for poor and excluded groups and with UNICEF and WHO in quality of care and standards of clinical practice for the sick newborn. Quality Tools A wide range of quality improvement tools are in use, to address different aspects of quality at different levels of the system, all of which have been developed in collaboration with the Department of Health Services. The USAID H4L activity has worked to consolidate quality assurance tools from the skilled birth attendants package, family planning, the integrated management of newborn and childhood illness and HIV for use at a health post level. UNFPA has certified health services as adolescent friendly using a quality improvement and certification tool. JHPIEGO has been implementing a Standards Based Management and Recognition approach in hospitals and Nick Simons Institute has developed Minimum Service Standards for District Hospitals. WHO has been supporting a maternal and perinatal death surveillance and response system and DFID and GIZ support clinical mentoring for comprehensive and basic emergency obstetric care facilities focusing on improving clinical skills and practice. GIZ with support from KOICA will continue to work in Nuwakot district at the district hospital and lower level facilities on improving the information available for planning and budgeting, including: the eawpb, an electronic annual work plan and budgeting tool; DHIS-2, the information technology platform for the health management information system and piloting patient based information systems. 8. Risk Analysis There are a number of key risks that may affect the implementation of the activity and include: Federalism and Local Elections: As Nepal moves towards a new administrative structure and local elections, there is likely to be civil disruptions to the implementation of activity interventions which will need to be managed. Conflict sensitivity and do no harm: Ensure that project activities are maximizing positive and constructive dynamics in the context and communities in which they operate, and not exacerbating negative or destructive dynamics. A conflict sensitive approach reflects understanding of the context in which the project will operate; the interaction between the proposed intervention and that context; and innovative thinking for avoiding negative impacts and maximizing positive ones. The innovative thinking should inform and be reflected in adaptive management decisions. Frequent staff transfer, high absenteeism of government staff, and lack of basic supplies The frequent change in Ministers leads to the increasing politicization of the civil service, 29

30 especially at higher levels and results in key government personnel being transferred frequently. Additional issues at the district and health facility level include inappropriate placement of trained staffs (for instance, a skilled birth attendant posted in tuberculosis clinic) and high absenteeism of health workers for various reasons including off-site trainings and meetings. Similarly, Nepal continues to face ongoing stockouts of essential health commodities at all levels of the supply chain. The activity will need to consider engaging with a wide network of key stakeholders in order to manage this situation. Capacity building leads to sustainable improvements in service delivery and quality of care There will be areas in which the government has capacity but needs better tools and skills and areas in which the activity will need to temporarily substitute government staff as the required skills are new, innovative and/or posts are not sanctioned. Transition plans for capacity building approaches and for all activity staff will need to be developed and agreed with the government. Professional relationship with Government, USAID and other partners The success of this activity will be contingent upon its key personnel being able to develop and sustain successful relationships across a wide range of stakeholders. 9. Authorizing Legislation The authority for this NFO is found in the Foreign Assistance Act of 1961, as amended. For US organizations, 2 CFR 200, 2 CFR 700 and USAID Standard Provisions for U.S. Nongovernmental recipients will be applicable. The OMB circulars are available in the following link: While 2 CFR 200 and 2 CFR 700 do not apply directly to non-u.s. applicants, the Agreement Officer (AO) will use the standards of 2 CFR 200 and 2 CFR 700 and USAID Standard Provisions for Non U.S. Nongovernmental recipients in the administration of the award. [END OF SECTION A] 30

31 SECTION B: FEDERAL AWARD INFORMATION 1. Estimate of Funds Available and Number of Awards Contemplated Subject to the availability of funds, USAID intends to provide up to $25,000,000 in total funding over a five-year period. USAID intends to award one (1) Cooperative Agreement pursuant to this RFA. Actual funding amounts are subject to availability of funds. USAID is not responsible for any costs incurred for preparation and submission of the concept paper. Please note that there are multiple phases to this process and the final award will be determined after a Program Description is jointly developed between the selected organization and USAID may issue a pre-authorization letter to the selected recipient to ensure co-development phase costs. No costs chargeable to the proposed award may be incurred before receipt of either a written authorization letter from the AO or fully executed cooperative agreement. USAID reserves the right to fund any one or none of the applications submitted. 2. Start Date and Period of Performance for Federal Awards The period of performance anticipated for the Cooperative Agreement is five years. The estimated start date will be based upon the signature of the award by the Agreement Officer. 3. Substantial Involvement USAID plans to negotiate and award a Cooperative Agreement as USAID desires to be substantially involved in the implementation of the selected program that is consistent with USAID policy contained in Automated Directives System (ADS) Chapter 303 concerning nongovernmental assistance activities. This substantial involvement will be through the Agreement Officer, except to the extent that the Agreement Officer delegates authority to the Agreement Officer's Representative (AOR) in writing. USAID/Nepal will be substantially involved with the Recipient during the performance of the Cooperative Agreement to ensure that implementation proceeds as planned and is consistent with the Mission s Development Objectives. USAID/Nepal will be involved in the following areas: i. Approval of Recipient s implementation work plan: The annual work plans and revisions thereto, are subject to AOR approval prior to implementing substantive work for each year of the Agreement. ii. Approval of specified Key Personnel: the Key Personnel positions will be identified and stated in the award. Recipient shall request prior approval from the USAID Agreement Officer for the replacement of key personnel or changes in the key personnel positions. 31

32 iii. Approval of Performance Monitoring and Evaluation Plan: the Recipient's Performance Monitoring and Evaluation Plan and revisions thereto are subject to AOR approval. iv. Sub-recipients and sub-awards: the USAID AO, or as delegated AOR, must concur with the selection and de-selection of sub-recipients, including those under the local grants fund, and the substantive provisions of the sub-awards. v. Agency Authority to Immediately Halt a Construction Activity: The AO may immediately halt a construction activity if identified specifications are not met. 4. Title to Property Property title under the resultant cooperative agreement shall vest with the recipient in accordance with the requirements of 2 CFR and 2 CFR regarding use, accountability, and disposition of such property. 5. Authorized Geographic Code The authorized geographic code for this Project is 937. Code 937 is defined as the United States, the cooperating/recipient country, and developing countries other than advanced developing countries, and excluding prohibited sources. Procurement of agricultural commodities and related products, motor vehicles and pharmaceuticals is subject to the limitations in 22 CFR and may require a waiver. 6. Purpose of the Award The principal purpose of the relationship with the Recipient and under the subject program is to transfer funds to accomplish a public purpose of support or stimulation of the Health System Strengthening project which is authorized by Federal statute. The successful Recipient will be responsible for ensuring the achievement of the program objectives and the efficient and effective administration of the award through the application of sound management practices. The Recipient will assume responsibility for administering Federal funds in a manner consistent with underlying agreements, program objectives, and the terms and conditions of the Federal award. The Recipient using its own unique combination of staff, facilities, and experience, has the primary responsibility for employing whatever form of sound organization and management techniques may be necessary in order to assure proper and efficient administration of the resulting award. [END OF SECTION B] 32

33 1. Eligible Applicants SECTION C: ELIGIBILITY INFORMATION USAID seeks to make awards to a U.S. or non-u.s. non-governmental organization (NGO) or a private, non-profit organization (or a for-profit company willing to forego profits) that has concrete assets for strengthening equitable and quality service delivery within national and local policies and implementation plans. This includes a strong track record in implementation, monitoring & evaluation (M&E), local capacity building with a focus on learning and use of data for decision-making, and credibility in policy engagement processes. Since USAID aims to work with experienced organizations to focus on and build local and community capacity, USAID will not provide separate technical assistance to partners. Any anticipated technical assistance needs (i.e., for M&E, knowledge management, etc.) must be built into activity design. In the case of a consortium, the Applicant must be the consortium lead and must identify any other members of the consortium or individuals tied to the implementation of the activity as described in the application, along with all sub-awardees. The respective roles of any other members of the consortium or individuals, including all sub- awardees, must be described and separate budgets must be attached for each. USAID welcomes applications from organizations that have not previously received financial assistance from Applicants must have established financial management, monitoring and evaluation processes, internal control systems, and policies and procedures that comply with established U.S. Government standards, laws, and regulations. To be eligible for a Cooperative Agreement, an organization must be any of the following types of organizations: 1. Non-Federal Entities (referred to as U.S. NGO) U.S. NGOs that meet the definitions in 2 CFR Nonprofit Organization (also referred to as U.S. NGO) U.S. non-profit organizations that meet the definition in 2 CFR Foreign Entities (referred to as non-u.s. NGOs) either non-profit or for profit organizations not affiliated with a foreign government that meet the definition in 2 CFR Applicants must have established financial management, monitoring and evaluation processes, internal control systems, and policies and procedures that comply with established U.S. Government standards, laws, and regulations. The successful applicant(s) will be subject to a responsibility determination assessment (Pre-award Survey) by the Agreement Officer (AO). The Recipient must be a responsible entity. The AO may determine a pre-award survey is required to conduct an examination that will determine whether the prospective recipient has the necessary organization, experience, accounting and operational controls, and technical skills or 33

34 ability to obtain them in order to achieve the objectives of the program and comply with the terms and conditions of the award. 2. Cost Sharing or Matching Cost sharing is an important element of the USAID-Recipient relationship and is required for this award. In addition to USAID funds, Applicants are required to contribute resources from their own, or other sources for the implementation of this activity. Cost share under the proposed award is required to be at least 10% of the total estimated amount provided by USAID/Nepal (excluding the amount of the proposed cost share). Cost sharing must be consistent with the requirements in 2 CFR , including, but not limited to, consisting of allowable costs under the applicable USG cost principles. 3. Qualifications for key personnel Chief of Party 100% LOE A Master s degree in public health, international development or a related field, or a Bachelor s degree, preferably in public health, international development, or a related field and 5-years experience, in addition to the 10 years outlined below At least 10 years of progressively increasing responsibility in managing health (maternal, newborn, child health and/or family planning) activities of this size and scope in developing countries and preferably in Asia Demonstrated ability to lead and manage a diverse team, in a flexible and adaptive programming context, ensuring high performance and staff retainment Ability to manage and develop relationships with a wide range of stakeholders, including proven experience of working closely with Government officials Proven technical knowledge in maternal, newborn, child health and family planning and in at least one of the following: health system strengthening, health governance and quality of care. Demonstrated leadership as a Chief of Party or Deputy Chief of Party for a large, multifaceted health development activity Proven written and oral presentation skills in professional business English Deputy Chief of Party 100% LOE A Master s degree in development sector, preferably public health, or a Bachelor s degree, preferably in public health and 3-years experience, in addition to the 8 years outlined below At least 8 years of progressively increasing responsibility in managing health (maternal, newborn, child health and/or family planning) activities, in Asian and preferable in Nepal Proven technical knowledge in maternal, newborn, child health and family planning and in relationship to the cross-cutting objectives of the activity Sufficient managerial and administrative experience to be able to deputize for the CoP in his/her absence Proven written and oral presentation skills in English 34

35 Monitoring, Evaluation and Learning Manager 100% LOE A Master s degree in epidemiology, statistics, research methods or related field or a Bachelor s degree and 3-years experience, in addition to the 5-years outlined below At least 5 years of working in health activities on monitoring, evaluation and research methods with increasing levels of responsibility in Asia and preferably in Nepal Experience in monitoring and evaluation work for in large, complex, and multifaceted health development activities Demonstrated ability to articulate technical information clearly and effectively and in flexible and adaptive programming Proven written and oral presentation skills in English Finance and Operation Manager 100% LOE A minimum of six years of experience in financial and administrative management of large international development projects. Demonstrated experience with financial and administrative systems of large international development projects. Experience managing financial transactions on USAID-funded programs and familiarity with USAID regulations and procedures. A post-graduate degree in Business, Accounting, Finance or related field. Strong management and interpersonal communication skills. Proven written and oral presentation skills in English Excellent working knowledge in MS Office Applications. [END OF SECTION C] 35

36 SECTION D: APPLICATION AND SUBMISSION INFORMATION The Government intends to award a Cooperative Agreement. The Health System Strengthening (HSS) assistance selection is being conducted in accordance with 2 CFR 200, 2 CFR 700 and ADS Chapter 303 through the use of a multi-tiered review process consisting of the following phases: I. Concept Paper: Applicants will submit concept papers that respond to the objectives outlined in this NFO. USAID will then conduct a merit review of the concept papers. The organizations submitting the most highly rated concept papers will be invited to the oral presentation phase. Applicants not advancing to the oral presentation phase will be provided sorry letters. No budget or cost application will be accepted at this stage. Questions and weaknesses resulting from the merit review will be shared with all applicants, and those invited to the oral presentation phase will be expected to address the questions and weaknesses during oral presentations. II. Oral Presentation: Applicants invited to participate in the oral presentation phase must appear in person in Kathmandu, Nepal. The proposed Chief of Party must lead the presentation and the proposed Key Personnel are encouraged to be present and to participate. The maximum number of participants that can attend on behalf of each Applicant is four (4) from the Prime applicant and one (1) from each major subcontractor (defined as any subcontractor expected to perform 20% or more of the scope of work). Applicants may opt to bring additional personnel for the purposes of preparing responses to Selection Committee (SC) questions, however a maximum of 5 persons will be allowed to formally participate in the oral presentations themselves. USAID will review each oral presentation against the merit criteria as defined in the NFO. Applicants not selected from the oral presentation phase will be notified. Costs associated with participation in the oral presentation phase are the sole responsibility of the applicant. One applicant will present per day. It is expected that there will be a maximum of 2 rounds of questions and answers per applicant during the day. Applicants will have opportunities to prepare responses to questions posed by the SC prior to each round. A top line summary budget must be presented during this phase. The slide-deck used during the oral presentations will become an official part of the source selection file and may be used for references purposes during evaluation. The initial slide-deck must be provided to the Agreement Officer 24 hours prior to the oral presentation so that the SC has sufficient time to review the slides. III. Joint Application Development: Following the oral presentation phase, the apparently successful Applicant will lead a process to collaborate with USAID, the Ministry of Health and other major stakeholders to develop a full program description. The duration of this process is expected to be 2 weeks. Thereafter, the applicant will have additional time to 36

37 prepare a final application, including a final Program Description, Monitoring, Evaluation and Learning Plan and a Cost Application with a detailed budget and budget narrative. This final application will then be evaluated as Pass/Fail. Agency Point of Contact Concept papers must be submitted electronically to the following address: kathmanduoaaexchange@usaid.gov. A. Deadline And Electronic Submission This announcement is found on the internet at Concept papers are due to USAID/Nepal by April XX, :00 a.m. Nepal Time. Concept papers should be received by the deadline. Incomplete or late concept papers may not be considered. For those Applicants invited to participate in the Oral Presentation phase, specific submission deadlines will be communicated in the invitation letters. All application files submitted must be compatible with Microsoft (MS) Office in a MS Windows environment and/or Adobe Acrobat (.pdf). The subject of each must read as follows: NFO: RFA Health Service Strengthening Applicants are reminded that is NOT instantaneous, in some cases delays of several hours occur from transmission to receipt. For this NFO the initial point of entry to the government infrastructure is USAID/Nepal mail server. Applicants must retain for their records copy of the s and application and all enclosures which accompany the application. Telegraphic or faxed application is not authorized for this NFO and shall not be accepted. Questions/clarifications regarding this RFA must be submitted via to kathmanduoaaexchange@usaid.gov no later than the time indicated on the Cover Letter, and as amended. The response to all the questions and clarifications received from the prospective Applicants will be posted as an Amendment to the RFA in the: B. Submission Process 1. Applicants will submit a concept paper as described below under C.1 by the due date and time on the Cover Page. 2. USAID/Nepal will review concept paper submissions and invite the Applicants with the most highly rated concept papers to the oral presentation phase. Oral presentations are described in C.2 below. 37

38 3. Finally, the apparently successful Applicant based on the review of the oral presentations will be invited to participate in the Joint Development of the program description with USAID/Nepal. The full application requirements and merit review criteria will be provided only to the apparently successful Applicant. C. Content and Format of Application Submission Content and format instructions must be followed, or Applicants risk being found non-compliant and eliminated from the review. Regardless of concept paper or full application, the following requirements apply for all electronic documents, with the exception of Government-issued forms: 8.5 x11 with 1 margins. Written in English. 12-point Times New Roman font for all narrative and tables. Graphics/charts may use 10-point Times New Roman font. Submitted via Microsoft Word or PDF formats, except budget files which must be submitted in Microsoft Excel (without deleting formulas). Budgets should show U.S. Dollars (USD), and if a non-u.s. NGO Applicant, also the local currency and the currency exchange rate used. Applicants who include data that they do not want disclosed to the public for any purpose or used by the U.S. Government except for review purpose, should mark the title page with the following legend: This [concept paper/application] includes data that shall not be disclosed outside the U.S. Government and shall not be duplicated, used, or disclosed in whole or in part for any purpose other than to evaluate this application. If, however, a cooperative agreement is awarded to this Applicant as a result of or in connection with the submission of this data, the U.S. Government shall have the right to duplicate, use, or disclose the data to the extent provided in the resulting cooperative agreement. This restriction does not limit the U.S. Government s right to use information contained in this data if it is obtained from another source without restriction. The data subject to this restriction are contained in sheets {insert sheet numbers} and, mark each sheet of data it wishes to restrict with the following legend: Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this application. C.1 Concept Paper Requirements Concept papers are limited to eight (8) pages, excluding the cover page and introduction. 1. The cover page is limited to one (1) page and must include the following: i. Concise title of activity; ii. NFO Number; 38

39 iii. Name and address of the Applicant organization; iv. Type of organization (e.g., for-profit, non-profit, university, network, etc.); v. DUNS Number; vi. Contact point (name, telephone, and ); and vii. Names of major sub-recipients. 2. The introduction is limited to one (1) page and must summarize the Applicant and/or its concept paper. 3. The concept paper content must be organized by the concept paper merit review criteria. C.2 Oral Presentation Format The oral presentation is an opportunity for the Applicant to conveying their knowledge, skills and abilities. Only the technical components will be discussed. The oral presentation must be organized by the format of the merit review criteria. Cost Application A top line summary budget must be presented during the Oral Presentation phase by applicants whose concept papers are selected by USAID as most highly rated. USAID will select one apparently successful Applicant from the oral presentation for Joint development of a full program description. After the program description is finalized by USAID, the apparently successful Applicant will be requested to submit a Cost Application with a detailed budget and budget narrative. The apparently successful applicant will be asked to include the following documents with their cost application: 1. SF-424 and SF-424A: A budget for each program year with an accompanying detailed budget narrative which provides in detail the total costs for implementation of the program. The budget must be submitted using Standard Form 424 which can be downloaded from the following web site at: 2. Budget Narrative The application must have an accompanying detailed budget narrative and justification that provides in detail the total program amount for implementation of the program your organization is proposing. The budget narrative should provide information regarding the basis of estimate for each line item, including reference to sources used to substantiate the cost estimate (e.g. organization's policy, payroll document, vendor quotes, etc.). A breakdown of all costs associated with the program according to the costs of, if applicable, headquarters, regional and/or country offices. Applicants who intend to utilize 39

40 contractors or sub-recipients should indicate the extent intended and a complete cost breakdown. Extensive contracts/agreement financial plans should follow the same cost format as submitted by the primary Applicant. A breakdown of all costs according to each partner organization, contract or sub/awardee involved in the program should be provided. Pursuant to 2 CFR 200 Contract means a legal instrument by which the Applicant purchases property or services needed to carry out the project or program under a resulting award. The term does not include a legal instrument when the substance of the transaction meets the definition of a Federal award or sub-award (see Subaward), even if the Applicant considers it a contract. The Applicant must work to be performed, the risk borne by the contractor, the contractor's investment, the amount of subcontracting, the quality of its record of past performance, and industry profit rates in the surrounding geographical area for similar work. 3. Cost Sharing: Applicants should estimate the amount of cost-sharing resources to be mobilized over the life of the agreement and specify the sources of such resources, and the basis of calculation in the budget narrative. Applicants should also provide a breakdown of the cost share (financial and in-kind contributions) of all organizations involved in implementing the resulting Assistance award. 4. Negotiated Indirect Cost Rate Agreement: The Applicant must submit a Negotiated Indirect Cost Rate Agreement NICRA if the organization has such an agreement with an agency or department of the U.S. Government. If no NICRA the Applicant should submit one of the following: Reviewed Financial Statements Report: a report issued by a Certified Public Account (CPA) documenting the review of the financial statements was performed in accordance with Statements on Standards for Accounting and Review Services; that management is responsible for the preparation and fair presentation of the financial statements in accordance with the applicable financial reporting framework and for designing, implementing and maintaining internal control relevant to the preparation. The account must also state the he or she is not aware of any material modifications that should be made to the financial statements; or Audited Financial Statements Report: An auditor issues a report documenting the audit was conducted in accordance with Generally Accepted Auditing Standards (GAAS), the financial statements are the responsibility of management, provides an opinion that the financial statements present fairly in all material respects the financial position of the company and the results of operations are in conformity with the applicable financial 40

41 reporting framework (or issues a qualified opinion if the financial statements are not in conformity with the applicable financial reporting framework. 5. Unique Entity Identifier and System for Award Management: USAID may not award to an applicant until the applicant has complied with all applicable unique entity identifier and SAM requirements. Each applicant is required to: (i) (ii) (iii) Be registered in SAM before submitting its application. SAM is streamlining processes, eliminating the need to enter the same data multiple times, and consolidating hosting to make the process of doing business with the government more efficient.; Provide a valid unique entity identifier in its application; and Continue to maintain an active SAM registration with current information at all times during which it has an active Federal award or an application or plan under consideration by a Federal awarding agency. 6. Certifications & Assurances: The applicant shall complete and return the certifications as per ADS Pre-Award Certifications, Assurances, and Other Statements of the Recipient. [END OF SECTION D] 41

42 SECTION E: APPLICATION REVIEW INFORMATION A. Merit Review Criteria for Concept Papers The merit review criteria prescribed herein are tailored to the requirements of this particular NFO. Applicants should note that these criteria serve to: (a) identify significant matters which the Applicants should address in their applications, and (b) set the standard against which all applications will be evaluated. The factor of Technical Approach is more important than the factors of Management Approach and Key Personnel, which are of equal weight. 1. Technical Approach The extent to which the Applicant demonstrates a strong, evidence-based and locally focused approach to achieving the program objectives, including a timeline with clear and realistic milestones, appropriate partnerships with the Government of Nepal, USAID and other stakeholders, and the incorporation of gender equality and social inclusion. 2. Management Approach The extent to which the Applicant demonstrates the organizational capacity to achieve the technical approach, clear and appropriate roles and responsibilities and the ability to collaborate with proposed sub-recipients and partners to support the technical approach. 3. Key Personnel The extent to which the Key Personnel meet the requirements in Section IV of the Program Description and will contribute to the probability of success of the technical approach. B. Merit Review Criteria for Oral Presentations [The oral presentation will be reviewed based on the following merit review criteria, which contain both technical and communication factors, which are of equal weight. 1. Technical Comprehension The extent to which the oral presentation participants communicate a comprehensive understanding of how the application will achieve the program objectives and successfully respond to TEC panel and oberver questions. 2. Response to Weaknesses and Clarifications The extent to which the Applicant made clear improvements to the questions and weaknesses provided as feedback during the Concept Paper phase and built on their Concept Paper to 42

43 provide a more detailed and stronger Technical Approach, Management Approach and Key Personnel. 3. Monitoring, Evaluation and Learning (MEL) The extent to which the oral presentation participants communicate a clear methodology that facilitates adaptive learning and management, and a logical approach for utilizing data to adaptively manage interventions. 4. Team Strength The extent to which the oral presentation participants demonstrate a strong team dynamic, a clear understanding of their individual roles, strong communication skills and a readiness to be involved and committed to achieving the program objectives. C. Merit Review Criteria for Final Application This phase will be reviewed as Pass/Fail. [END OF SECTION E] 43

44 SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION 1. Federal Award Notices Award of the agreement contemplated by this NFO cannot be made until funds have been appropriated, allocated and committed through internal USAID procedures. While USAID anticipates that these procedures will be successfully completed, potential Applicants are hereby notified of these requirements and conditions for the award. The AO is the only individual who may legally commit the Government to the expenditure of public funds. No costs chargeable to the proposed Agreement may be incurred before receipt of either a fully executed Agreement or a specific, written authorization from the AO. Following the selection for award and successful negotiations, a successful Applicant will receive an electronic copy of the notice of the award signed by the AO, which serves as the authorizing document. The AO will only do so after making a positive responsibility determination that the applicant possesses, or has the ability to obtain, the necessary management competence in planning and carrying out assistance programs and that it will practice mutually agreed upon methods of accountability for funds and other assets provided by The award will be issued to the contact as specified in the application as the Authorized Individual in accordance with the requirements in the Representations and Certifications. For organizations that are new to working with USAID or for organizations with outstanding audit findings, USAID may perform a pre- award survey to assess the applicant s management and financial capabilities. If notified by USAID that a pre-award survey is necessary, applicants must prepare, in advance, the required information and documents. Please note that a pre-award survey does not commit USAID to make any award. 2. Administrative and National Policy Requirements The resulting award from this NFO will be administered in accordance with the following policies and regulations. For US organizations: ADS 303, 2 CFR 700, 2 CFR 200, and Standard Provisions for U.S. Nongovernmental organizations. For Non US organizations: ADS 303, Standard Provisions for Non-U.S. Non-governmental Organizations. The links to these regulations are as follows: ADS-303: 2 CFR 700: =pt &rgn=div5 2 CFR 200: 44

45 idx?tpl=/ecfrbrowse/title02/2cfr200_main_02.tpl Standard Provisions for U.S. Nongovernmental Recipients can be accessed through USAID s website Standard Provisions for Non-U.S., Nongovernmental Recipients can be accessed through USAID s website C. Reporting Requirements Applicants should note that the schedule for submitting annual work plans, and quarterly progress and annual performance reports will be in line with the Government of Nepal GON fiscal year and annual performance reporting schedule, mid-july to mid-july of each year. All USAID/Nepal health programs report on results according to this schedule allowing consolidated and synchronous reporting to USAID/Washington. This also allows for using results data that are reported as part of the Government of Nepal s annual work cycle. USAID will develop a reporting schedule with the Recipient during the start-up phase of the activity to provide final guidance on this. 1. Annual Work Plan Within 45 days of signing the agreement, the Recipient will submit an Annual Work Plan for Year 1, designed in consultation with USAID and key stakeholders including the Government, USAID and other implementing partners. Work plans are expected to reflect extensive discussions and joint planning exercises. The Annual Work Plan for Year 1 should delineate the Recipient's Mobilization Plan for activity start-up activities during the period of overlap with the current H4L activity to ensure a smooth transition from the current activity to the new activity. Annual work plans for subsequent years are due 45 days before the end of the preceding award year. This and subsequent Annual Work Plans, will describe the activities and interventions to be carried out and the corresponding time frames. The proposed activities and interventions shall fall within the approved Program Description of the Cooperative Agreement with Each newly proposed activity in the annual work plan shall be justified with measurable results which clearly contribute to achieving one or more activity objectives. The Annual Work Plan will also incorporate an annual budget plan and, from year 2 onward, a Financial Report on the prior year s expenditures. USAID will review and approve plans and ensure that they are within the Program Description. Work plans changes and/or revisions shall describe activities at a greater level of detail than the Program Description, but shall not serve to change the Program Description in any way. Therefore, all work plans changes and/or revisions thereto shall cross-reference the applicable section(s) in the Program Description. The Program Description shall take precedence over the work plans and any changes and/or revisions thereto, in the event of any conflicts or inconsistencies between the Program Description and the work plans and any changes and/or revisions thereto. The AO must approve any changes to the Program Description by means of a 45

46 modification to this Agreement. The work plan will include: i. Progress towards achieving performance measures and results agreed upon within the MEL Plan; ii. (Year 2 and later only) Any new activities planned and their justification. iii. Timeline for implementation of the year s proposed activities, including target completion dates; iv. Information on how activities will be implemented; v. Personnel requirements to achieve expected outcomes; vi. Major commodities or equipment to be procured, an explanation of the intended use of each item and the source and origin of each item; vii. Details of collaboration with other major partners, including how activities will be coordinated with other USAID Implementing Partners; viii. Detailed budget, which aligns with the approved Cooperative Agreement budget. ix. International travel planned for the year. 2. Monitoring, Evaluation and Learning (MEL) Plan A full MEL Plan must be jointly developed during the Joint Development phase. The Recipient is required to have a MEL Plan capable of tracking and documenting progress against activity objectives. The MEL Plan must be reviewed annually alongside the Annual Work Plan in collaboration with USAID and may need to be adapted to evolving activity requirements and those from The Recipient is required to work with the USAID to ensure that the MEL plan aligns with the USAID/Nepal Performance Management Plan (PMP). USAID and the Recipient will conduct periodic performance reviews to monitor the progress of work and the achievement of results as based on the targets specified in the MEL Plan. The MEL Plan must include: (i) A Results Framework (RF) and simplified Foreign Assistance Framework that reflect the objectives described in the award; (ii) Development hypothesis and critical assumptions; (iii) Baseline values and targets to show progress over time. Baselines must be established within 3 months of the award; (iv) Performance data table summarizing key performance monitoring information; (v) Performance indicator reference sheets for each indicator that include a description of the indicator to be tracked, source, method and schedule of data collection, known data limitations and plans to address the limitations; (vi) Geolocated indicators results and beneficiaries; (vii) Capacity building in evidence and data use (viii) Knowledge products and dissemination plans; and (ix) Evaluation approach to inform adaptation and learning. 3. Progress and Performance Reports 46

47 The Recipient must submit Quarterly Progress Reports and Annual Performance Reports to USAID during the duration of this Agreement. These reports must be submitted within 30 days following the end of the reporting period. Quarterly Progress Reports must briefly present the following information: (i) (ii) (iii) (iv) A comparison of actual accomplishments versus targets by program objective; and reasons why established targets were not met, if applicable; Anticipated future problems or delays that may adversely affect implementation of the activity, including those related to security, management or administration; Other pertinent information including the status of finances and expenditures and, when appropriate, analysis and explanation of cost overruns or high unit costs; List of upcoming events with dates. Annual Performance Reports will be submitted in lieu of a quarterly progress report. Annual Performance Reports must contain the following information: (i) (ii) (iii) (iv) (v) A comparison of actual accomplishments versus targets by activity objective for the reporting period using quantitative data; and reasons why established targets were not met, if applicable; Financial update, including expenditure data and, when appropriate, analysis and explanation of cost overruns or high unit costs; Information on problems or delays that affected implementation, including those related to management or administration; Documentation of best practices and lessons learnt; Prospects for the next year s performance 4. Financial Reports Financial Reports must be in keeping with 2 CFR In accordance with 2 CFR , the SF-425 will be required as follows: i. The Recipient must submit the Federal Financial Form (SF-425) on a quarterly basis via electronic format to the AO, AOR, and the USAID/Nepal Controller. These reports must be submitted within 30 calendar days from the end of each quarter, except that the final report must be submitted within 90 calendar days from the estimated completion date of this Agreement. ii. The Recipient must submit the original and two copies of all final financial reports to USAID/Washington, M/CFO/CMPLOC Unit, the AO, the AOR, and the USAID/Nepal Controller. 5. Special Reports From time to time, the Recipient may be requested to prepare and submit to USAID special reports concerning specific activities and topics. Short term consultants reports must be submitted to USAID in a mutually agreed upon format and time frame. 47

48 6. Final Report The Recipient must submit the Final Report to USAID no later than 90 days after the completion date of the Cooperative Agreement. The Final Report must include: (i) (ii) (iii) (iv) Executive summary of the Recipient s technical approach and accomplishments in achieving results; The program model and its implementation in enough detail to allow for replication, including information on: theory of change; interventions and approaches; inputs, outputs, and processes; final performance indicator data; number of people and communities benefited, by each separate component and by multiple components (integration), compared to targets, and for how long; and cost; Overall assessment of progress made toward accomplishing the goal, purpose and objectives, any important research findings, a description of major products or tools; Financial report that describes how the Recipient s funds were used. See 2 CFR Management Reviews and External Evaluations The annual work plans will form the basis for joint annual management reviews by USAID and program staff to review activity directions, achievement of the prior year work plan objectives, any major management and implementation issues, and to make recommendations for any changes as appropriate. These management reviews as well as work plan meetings may be broadened to include dialogue across the different cooperating agencies, and among relevant Ministries. At any time during activity implementation, USAID may conduct one or more external assessments to review overall progress through independent, external evaluators to assess the continuing appropriateness of the activity design, and identify any factors impeding effective implementation. USAID will utilize the results of the assessments to recommend any changes in strategy if needed and to help determine appropriate future directions. Site visits may occur any time after startup. 8. Development Data The recipient must submit to the Development Data Library (DDL) at in a machine-readable, non-proprietary format, a copy of any Dataset created or obtained in performance of this award, including Datasets produced by a sub-awardee or a contractor at any tier according to the instructions found at The submission must include supporting documentation describing the Dataset, such as code books, data dictionaries, data gathering tools, notes on data quality, and explanations of redactions." 9. Development Experience Clearinghouse Requirements The Recipient is required to submit any technical reports produced under this activity, in English, to USAID s Development Experience Clearinghouse (DEC) according to the instructions found at 48

49 10. Emergency Preparedness and Response Plan Nepal is a seismically active zone and is considered at high risk of earthquakes. Minor tremors are not uncommon. Earthquakes are impossible to predict and can result in major devastation and loss of life. There are several websites focusing on earthquakes preparedness, including The Emergency Preparedness Guide created by the U.S. Embassy Nepal's Consular Section at % pdf is an additional resource. In the event of a major disaster or earthquake, entities operating in Nepal must be prepared to be self-sufficient. To facilitate earthquake preparedness, USAID requires implementing partners to develop sound Emergency Preparedness and Response Plans (EPRP). USAID also requests implementing partners incorporate disaster risk reduction into their activities. 1. Disaster Risk Reduction: Disaster risk reduction - addressing vulnerabilities to, and preparation for, anticipated and recurring natural hazards - requires sound awareness and advocacy within the government, external development partners, civil society and the general public. The Implementer is encouraged to promote disaster resilience and continually seek creative opportunities for incorporating disaster risk reduction into program activities. This includes such activities as awareness raising and advocacy for emergency preparedness and disaster risk reduction within the Government of Nepal. The Implementer is expected to ensure that project training where appropriate and as directed includes appropriate emergency preparedness and disaster risk reduction elements. 2. Preparedness: The Implementer must prepare for the impact that a large disaster would have on both staff and program implementation through the preparation of an Emergency Preparedness and Response Plan (EPRP). EPRPs must be brief (several paragraphs to one page) and contain the following: Table of Contents 1. Primary contacts within the Implementer's organization and sub-partners. Please note if back up communications (radio, sat phone) are available. 2. Primary contacts within USAID/Nepal (in the event of a mega disaster, USAID wants to maximize the possibility of awardees being able to contact USAID) o Agreement/Contract Officer's Representative (A/COR) in Kathmandu o Alternate A/COR o Office Director o Office Deputy Director 49

50 o Contracting Officer (CO)/ Agreement Officer (AO) 3. Plans for information and educating staff including plans for drills. 4. Resource List identifying items on-hand and items for purchase which may include items such as solar-powered satellite phones with numbers, contents of go-bags and stay-bags, portable generators, essential survival equipment first-aid and other medical resources, etc., and their locations, for example, address of building in VDC, or vehicles identification. 5. Description of post-disaster recovery activities within the manageable interest of the partner which could be undertaken in the case of a natural disaster. The Implementers should not dedicate resources for disaster response beyond preparedness for responding to staff needs. However, partners should be prepared for contingencies including the possibility that USAID may modify activities within the award as a result of a disaster. The EPRP is due for submission to the A/COR within 90 days after the effective date of this award/modification unless noted otherwise in the delivery schedule of the award/modification. Page 4 The Implementer is expected to inform its staff about the contents of its EPRP through training and drills or other similarly effective methods. Additionally, the Implementer can request the U.S. Embassy to share details of its own earthquake preparedness planning for staff. The brevity required for the EPRP submission to USAID does not in any way restrict the Implementer from developing a fuller emergency preparedness manual for use by project management and staff. 11. Program Income Applicants are requested to mention in the concept papers and eventual applications whether program income is anticipated under the resulting award. If an activity under the award generates a profit, in accordance with 2 CFR and the prior written approval of the AO, USAID may use program income to finance the non-federal cost share of an award. The AO may also make the program income additive to USAID s contribution without a cost sharing requirement when this would help achieve program objectives, such as sustainability. 12. Environmental Compliance As part of its initial Work Plan, and all Annual Work Plans thereafter, the Recipient, in collaboration with the USAID AOR and Mission Environmental Officer or Bureau Environmental Officer, as appropriate, shall review all ongoing and planned activities under the activity to determine if they are within the scope of the approved 2 2 Code of Federal Regulations (CFR) 216 environmental documentation. If the Recipient plans any new interventions outside the scope of the approved Regulation 216 environmental documentation, it shall prepare an amendment to the documentation for USAID review and approval. No such new interventions shall be undertaken prior to receiving written USAID approval of environmental documentation amendments. Any ongoing interventions found to be outside the scope of the approved Regulation 216 environmental documentation shall be halted until an amendment to the documentation is 50

51 submitted and written approval is received from In addition, the Recipient must comply with host country environmental regulations unless otherwise directed in writing by In case of conflict between host country and USAID regulations, the latter shall govern. The Request for Categorical Exclusion (RCE) on environmental impact analysis can be found in annex Branding Strategy and Marking Plan The apparently successful applicant will be required to submit a Branding Strategy and Marking Plan to be reviewed and approved by the Agreement Officer. A Branding Implementation Strategy and Marking Plan must be in accordance with USAID Branding and Marking Plan as required per ADS 320 at the following link: The Recipient must comply with the requirements of the USAID Graphic Standards Manual available at or any successor branding policy. [END OF SECTION F] 51

52 SECTION G: FEDERAL AWARDING AGENCY CONTACT(S) A. FOR APPLICATION AND INQUIRY USAID/Nepal s address is as follows for inquiries and/or submissions of concept papers/applications: kathmanduoaaexchange@usaid.gov. B. AGREEMENT OFFICER S REPRESENTATIVE The AOR and Alternate AOR will be designated prior to award of cooperative agreement. The AOR designation letter will be provided to the Recipient and to the relevant offices of USAID/Nepal. [END OF SECTION G] 52

53 SECTION H: OTHER INFORMATION List of Annexes Annex 1 Sample of Results Framework Annex 2 - USAID/Nepal CDCS Results Framework and Relationship to activity Annex 3 - Gender Equality and Social Inclusion Analysis Annex 4 - Categorical Exclusion Annex 5 - Conflict Sensitive Development Programming 53

54 Annex 1: Sample of Results Framework The results framework proposes a number of different illustrative indicators taken predominantly from NHSS ( ) and from the USAID/Nepal Office of Health and Education (2016) Health Indicators and Definition Handbook. PURPOSE - Improved health status, particularly for the most marginalized and disadvantaged groups, by strengthening data driven planning and governance of a decentralized health system, to increase access and utilization of equitable, accountable and quality maternal, child health and family planning services, with specific focus on the newborn. ILLUSTRATIVE INDICATORS Newborn mortality rate Maternal Mortality rate OUTCOME 1 Improved access to and utilization of healthcare services ILLUSTRATIVE INDICATORS Number and percent of newborns receiving postnatal health check within 24 hours Number and percent of demand satisfied for family planning (by wealth) OUTPUT 1.1 Basic package of services available at all health facilities & through outreach ILLUSTRATIVE INDICATORS Number of newborn infants receiving appropriate antibiotic treatment for infection Availability of FP methods by level of facility Number and percent of postpartum women accepting FP OUTPUT 1.2 Barriers to accessing services reduced ILLUSTRATIVE INDICATORS Number and percent of clients who received basic health services free of cost Number and percent of institutional deliveries (by wealth quintile, by caste/ethnicity) 54

55 Annex 2 - USAID/Nepal CDCS Results Framework and Relationship to activity 55