Health Systems Strengthening Project (HSSP)

SOL-668-12-000003

Health Systems Strengthening Project (HSSP)

Issue Date: March 30, 2012

Deadline for Question/

Clarifications: April 11, 2012

Closing Date: May 10, 2012

Closing Time: 5pm South Sudan time

Subject: Request for Applications (RFA) Number: SOL-668-12-000003

RFA Title: Health Systems Strengthening Project (HSSP)

Ladies/Gentlemen:

The United States Agency for International Development (USAID) is seeking applications from qualified U.S. and Non-U.S. organizations for a cooperative agreement to fund a project entitled “Health Systems Strengthening Project (HSSP).” The authority for the RFA is found in the Foreign Assistance Act of 1961, as amended.

While for-profit firms may participate, pursuant to 22 CFR 226.81, it is USAID policy not to award profit under assistance instruments, such as cooperative agreements. However, all reasonable, allocable, and allowable expenses, both direct and indirect, which are related to the agreement program, and are in accordance with applicable cost standards (22 CFR 226, OMB Circular A-122 for non-profit organization, OMB Circular A-21 for universities, and the Federal Acquisition Regulation (FAR) Part 31 for-profit organizations), may be paid.

Applicants under consideration for an award that have never received funding from USAID will be subject to a formal pre-award audit to determine fiscal responsibility, ensure adequacy of financial controls and establish an indirect cost rate (if necessary).

Subject to the availability of funds an award will be made to that responsible applicant(s) whose application(s) best meets the requirements of this RFA and the selection criteria contained herein. While one award is anticipated as a result of this RFA, USAID reserves the right to fund any or none of the applications submitted.

For the purposes of this RFA, the term "Grant" is synonymous with "Cooperative Agreement"; "Grantee" is synonymous with "Recipient"; and "Grant Officer" is synonymous with "Agreement Officer".

Please be advised that any questions/comments on the draft RFA have been received and they were considered in completing this RFA.

Eligible organizations interested in submitting an application are encouraged to read this RFA thoroughly to understand the type of project sought and the application submission requirements and evaluation process.

To be eligible for award, the applicant must provide all required information in its application, including the requirements found in any attachments to this Grants.gov opportunity. This RFA consists of this cover letter plus the following Sections:

Section I: Funding Opportunity Description

SECTION II: AWARD INFORMATION

SECTION III: ELIGIBILITY INFORMATION

SECTION IV: APPLICATION FORMAT GUIDELINES AND ASSUMPTIONS

SECTION V: APPLICATION REVIEW INFORMATION

Section VI, Award and Administration Information

SECTION VII: AGENCY CONTACTS

SECTION VIII: OTHER INFORMATION

This funding opportunity is posted on www.grants.gov, and may be amended. Potential applicants should regularly check the website to ensure they have the latest information pertaining to this RFA. Applicants will need to have available or download Adobe program to their computers in order to view and save the Adobe forms properly. If you have difficulty registering on www.grants.gov or accessing the RFA, please contact the Grants.gov Helpdesk at 1-800-518-4726 or via email at for technical assistance.

It is the responsibility of the recipient of this RFA document to ensure that it has been received from Grants.gov in its entirety. USAID bears no responsibility for data errors resulting from transmission or conversion processes associated with electronic submissions.

Please send any questions to with a copy to . The deadline for questions is April 11, 2012. Responses to questions will be furnished to all potential applicants through an amendment to this RFA.

Issuance of this RFA does not constitute an award commitment on the part of the Government nor does it commit the Government to pay for any costs incurred in preparation or submission of comments/suggestions or an application. In addition, final award of any resultant cooperative agreement cannot be made until funds have been fully appropriated, allocated, an committed through internal UAID procedures. While it is anticipated that these procedures will be successfully completed, potential applicants are hereby notified of these requirements and conditions for awards. Applications are submitted at the risk of the applicant. All preparation and submission costs are at the applicant’s expense.

Thank you for your interest in USAID/South Sudan programs.

Sincerely,

Mandy Parham-Seotsanyana

Contracting/Agreement Officer

TABLE OF CONTENTS

Section I: Funding Opportunity Description………………….………….4

SECTION II: AWARD INFORMATION………………………………………...…….27

SECTION III: ELIGIBILITY INFORMATION………………………………….……. 30

SECTION IV: APPLICATION FORMAT GUIDELINES AND ASSUMPTIONS….. 31

SECTION V: APPLICATION REVIEW INFORMATION…………………………….45

Section VI, Award and Administration Information……………..…53

SECTION VII: AGENCY CONTACTS…………………………………………………53

SECTION VIII: OTHER INFORMATION…………………………………………...…53

Section I: Funding Opportunity Description

A. General Description of Funding Opportunity

1. Introduction

The goal of the Health Systems Strengthening Project is to increase the ownership and capacity of County Health Departments (CHDs) and State Ministries of Health (SMOHs) to ensure the provision of high quality primary health care in Western Equatoria State (WES) and Central Equatoria State (CES). Through expanded capacity of health managers to oversee the provision of health care services, the Health Systems Strengthening Project will support the MOH in its goal to provide comprehensive primary health care to all people in South Sudan.

2. Background

South Sudan is a geographically vast country with a diverse population of approximately 8,260,490 (2008 census) million people. This region, historically separated into the Sudanese provinces of Bahr el Ghazal, Equatoria, and Upper Nile, but now divided into the 10 states of South Sudan, is home to over 110 ethnic groups, many of whom suffer from some of the world’s worst socio-economic conditions.

Shortly after independence of the prior united Sudan in 1956, the north and the south engaged in a prolonged civil war that caused over 2,000,000 deaths, displaced more than 4,000,000 people, and drove over 500,000 into refuge in other countries. The Comprehensive Peace Agreement (CPA), signed on January 9, 2005 between northern and southern Sudan, brought nearly 50 years of civil strife to an end. The interim period of the CPA expired in July 2011, and the Republic of South Sudan (ROSS) was created as a separate, independent nation on July 9, 2011.

The period following the signing of the CPA has brought a measure of peace and the beginning of development to the region. Since the establishment of the semi-autonomous Government of Southern Sudan (GOSS) in 2005, southern Sudanese leaders have prioritized system-wide and comprehensive development of all sectors, including health. However, challenges persist, including insecurity in the region, driven by competition for resources, longstanding ethnic rivalries, lack of food and essential services, high levels of corruption and minimal human and institutional capacity. The people of South Sudan are among the world's poorest, with more than half the population living on less than one dollar per day. South Sudan’s most recently UN-estimated gross domestic product (GDP) per capita of US$90 in 2009 is remarkably low, even by sub-Saharan African standards.

Enormous challenges face the health sector in South Sudan. The decades-long civil war between northern and southern Sudan led not only to the deaths and displacement of over four million people; it was also destructive of physical and social infrastructure. Hospitals and clinics were destroyed, and those that managed to remain open stagnated in terms of improving the range and quality of services offered, the competencies of service providers, and the quality of patient care. The loss of human development opportunities was extreme, including significant loss of experienced health professionals. Many of the weaknesses in South Sudan’s health systems, health infrastructure, and health providers’ skills are the consequence of this prolonged civil unrest.

Health System Status

Decentralized delivery of primary health care (PHC) services is envisioned as the cornerstone of equitable, quality health services. The public health system is beginning to recover from the war’s impact; however, significant challenges in staffing and infrastructure remain. Poverty and low population density impede the equitable distribution of health care providers and essential supplies and infrastructure. Improvements are urgently needed in all aspects of the health system, including infrastructure, human resources, pharmaceuticals procurement, and referrals. The absence of a functioning transport system, an extreme lack of roads and difficult terrain, especially during rainy season, create additional obstacles to health service delivery. Additionally, the availability of clean water, hygiene, and sanitation facilities, and waste disposal infrastructure are problems at many health facilities.

The health system currently experiences chronic shortages of medicines and medical supplies in health facilities, and a weak pharmaceutical regulatory system. Although a National Drug Policy has been drafted, stock-outs of medicines and commodities in the public sector to support service delivery continue to occur frequently. Currently, the Ministry of Health (MOH) manages drug procurement and distribution, including for the essential-medicines-kit program. One continuing challenge is that drugs are pushed by the Central Medical Stores (CMS) at unpredictable and infrequent periods to the health facilities via the states and counties, both which lack resources to ensure that distribution to facilities is conducted in a timely manner. The push system and delivery of kits results in an imbalance in deliveries of appropriate type and quantity. In part, this is generated from poor information systems, delayed national procurements, lack of an operational registration system, and limited quality assurance.

The shortage of health care providers and health care managers is stark. In addition to the general dearth of qualified physicians, nurses, midwives and managers, those who are currently working within the MOH system experience frequent problems with timely and appropriate remuneration, leading to job dissatisfaction and lack of motivation. Further complicating planning at present is the fact that the MOH is currently re-defining health worker cadres, especially community health workers and their respective roles and responsibilities. Few training schools are operational in South Sudan and many NGOs rely on citizens from countries throughout the region for services provision.

Further, there is limited capacity for planning and management at all levels of the GOSS, combined with inadequate data collection, analysis and utilization in decision making processes. In South Sudan, Village Health Committees (VHCs) play a role in ensuring quality service provision, and in liaising with the county health departments when there are problems with staffing or capacity at a facility level to deliver services. However, many VHC members are not fully aware of their role as advocates, facility managers, and liaisons with the MOH system. Financial management systems are nascent; causing difficulties with the flow of funds between the Ministry of Finance and Economic Planning (MOFEP) and the MOH, and planning, disbursement and expenditure of annual budget allocations is weak. These difficulties are impeding the regularity of salary payments to health care providers as well as funding for operational costs, supplies and maintenance in health facilities and at the county and state levels.

The MOH has sought to establish a single, coordinated health information system (HIS) since 2005. However, progress in its development was slow; thus, parallel systems were developed for disease-specific data capture and reporting. Significant delays, restrictions on the release of public health information, and one-way flow of information have hindered data use and quality, and patient records often are nonexistent at the primary care level. Despite lack of precise population data and health statistics, valuable health information is emerging, mostly through surveys and studies. The HIS system has been developed and piloted in certain counties, and is currently being expanded to all states, counties, and facilities. However, there is still much work to be done to support the roll-out of the system, and ensure that data is captured in a consistent, accurate manner.

The MOH has been active in developing policies to govern the health sector; however, many of these policies are not yet disseminated to or utilized at the facility level. There is a need to standardize services that are provided through the health system, and to ensure that policies are utilized appropriately.

During the war, health service provision was mainly provided by non-governmental organizations (NGOs) and faith-based organizations (FBOs). Under the CPA, the MOH resumed responsibility for rebuilding and transforming the public health system; however, NGO and FBO involvement in provision of health services remains vital for the sector. The MOH envisions that, ultimately, facilities will be supported and managed exclusively by the GOSS. This will be a process that takes place over the next several years, and is predicated on the MOH having sufficient funds to hire appropriate staff and provide sufficient resources for training, equipment, pharmaceuticals, and other operational expenses.

Population Health Status

South Sudan has a high burden of many diseases which results in poor health status, particularly of mothers, infants, and children under five years of age. Based on 2010 data, the average person lives only to age 59. Maternal and child morbidity and mortality indicators are among the worst in the world; 2,054 mothers die per 100,000 live births and there are 84 infant deaths per 1,000 live births, while the probability of dying before five years of age has been estimated at 106 per 1,000 live births (South Sudan Household Survey 2010). The South Sudan Household Survey results also indicate that almost one third (30.3 percent) of children under age five are underweight (either moderately or severely) and 13 percent are severely underweight. Poor child feeding practices compound the effects of poverty and food scarcity. Preventable infectious diseases (malaria, pneumonia and diarrhea) account for a majority of reported diagnosis in health facilities for all age groups, and are the most common causes of morbidity and mortality for children under five years of age. Less than 17.5 percent of children are fully immunized.

As alarmingly high as these mortality and morbidity figures are, they nevertheless reflect an improvement since 2006. Further reductions in maternal and child morbidity and mortality are thwarted, however, by limited access to maternal and neonatal services and a severe shortage of personnel with skills in life-saving maternal and neonatal care. Use of antenatal care (ANC) and facility-based labor and delivery services is extremely low in South Sudan; only 40 percent of all expectant women receive any ANC, and only 14 percent of women deliver in health facilities. Access to emergency obstetric and neonatal care (EmONC) is very low, and active management of the third stage of labor (AMSTL) is not available in many locations.

Of mothers delivering at home, only 10 percent are cared for by skilled health personnel. In all 10 states of South Sudan, midwives, traditional birth attendants (TBA) and other maternal and neonatal care providers lack the necessary training required to perform simple lifesaving or nursing procedures. Further, high levels of fertility and extremely low utilization of contraception contribute to high maternal mortality in South Sudan. The prevalence rate of modern contraceptives is only 1.5 percent and on average a woman bears seven children.