USAID/Ethiopia Lowland Health Activity

USAID/Ethiopia Lowland Health Activity is sponsored by USAID. A program aimed at improving health services in Ethiopia's lowland regions, including Afar.

Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity SECTION A: PROGRAM DESCRIPTION ............................................................................................................. 6 A. 1.

TITLE .................................................................................................................................................. 6 A. 2.

SUMMARY ......................................................................................................................................... 6 A. 3.

GOAL AND OBJECTIVES ...................................................................................................................... 7 A. 4.

BACKGROUND ................................................................................................................................... 8 4. 1.

Country Context ............................................................................................................................ 8 4. 2.

Problem Statement ..................................................................................................................... 12 4. 3.

Lessons Learned ................................................................................................................................ 15 A. 5.

ACTIVITY DESCRIPTION .................................................................................................................... 17 5. 1 Theory of Change ............................................................................................................................

18 5. 2. Activity Intermediate Results ......................................................................................................

18 > IR 1: Improved PHC Facility Governance and Functionality to Deliver Essential Services ..................................... 18 > IR 2: Improved Access to and Quality of Services through Client-Centered and Contextualized Service Delivery > Models ..................................................................................................................................................................

21 > IR 3: Improved Adoption of Healthy Behaviors, Including Utilization of Services ................................................. 24 > IR 4: Rehabilitated health facilities that provide essential RMNCAH-N services ................................................... 27 A.

6. GENERAL ACTIVITY GUIDANCE ........................................................................................................ 29 6.

1. Overarching Guiding Principles ................................................................................................... 29 6.

2. Geographic Focus ....................................................................................................................... 29 6.

3. Technical Approach .................................................................................................................... 30 6.

4. Gender and Inclusivity ................................................................................................................ 34 6.

5. Youth .................................................................................................................................................. 34 6.

6. Science Technology Innovation and Partnerships .............................................................................. 35 A.

7. INSTITUTIONAL LINKAGE, PARTNERSHIP AND COORDINATION ...................................................... 35 7.

1. Ministry of Health ....................................................................................................................... 35 7.

2. Regional Health Bureaus/ Zonal Health Departments ............................................................... 35 7.

3. Woreda (District) Health Offices ................................................................................................. 36 7.

4. USAID Implementing Partners .................................................................................................... 36 A.

8. POLICY FRAMEWORKS AND STRATEGIES ......................................................................................... 38 8.

1. Strategy to Revitalize HEP in the Pastoralist Areas of Ethiopia .................................................. 38 8.

2. The second Health Sector Transformation Plan (HSTP II) ........................................................... 38 8.

4. Health Extension Program Roadmap (2020-2035) ..................................................................... 38 A.

9. SUMMARY CONCLUSION OF ANALYSES ........................................................................................... 39 9.

1. National Health Extension Program (HEP) Assessment .............................................................. 39 9.

2. Gender Analysis .......................................................................................................................... 39 A.

10. LOCAL OWNERSHIP AND SUSTAINABILITY ....................................................................................... 44 A.

11. ACTIVITY MANAGEMENT APPROACH .............................................................................................. 45 SECTION B: FEDERAL AWARD INFORMATION ..............................................................................................

46 B. 1 E STIMATE OF FUNDS AVAILABLE AND N UMBER OF AWARDS CONTEMPLATED .................................................. 46 B.

2 E XPECTED P ERFORMANCE I NDICATORS , TARGETS , BASELINE DATA , AND DATA COLLECTION ............................... 46 B. 3 START DATE AND PERIOD OF P ERFORMANCE FOR FEDERAL AWARDS ..............................................................

46 B. 4 SUBSTANTIAL I NVOLVEMENT ........................................................................................................................... 46 B.

5 AUTHORIZED GEOGRAPHIC CODE ................................................................................................................... 47 B. 6 N ATURE OF THE RELATIONSHIP BETWEEN USAID AND THE RECIPIENT ...................................................................

48 SECTION C: ELIGIBILITY INFORMATION ........................................................................................................ 49 C. 1 E LIGIBLE APPLICANTS .....................................................................................................................................

49 C. 2 COST SHARING OR M ATCHING ........................................................................................................................ 49 C.

3 N UMBER OF APPLICATIONS THAT M AY BE SUBMITTED ......................................................................................... 49 SECTION D: APPLICATION AND SUBMISSION INFORMATION ..................................................................... 50 D.

1 AGENCY P OINT OF CONTACTS ................................................................................................................ 50 D. 2 Q UESTIONS AND ANSWERS ....................................................................................................................

50 Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity D. 3 GENERAL CONTENT AND FORM OF APPLICATION ........................................................................................ 50 D.

4 APPLICATION SUBMISSION P ROCEDURES ................................................................................................... 52 D. 4.

1 Technical Approach (see E. 5. 1) ...................................................................................................

55 D. 4. 2 Learning, Monitoring, And Evaluation (LME) Plan (see E.

5. 2) .................................................... 55 D.

4. 3 Staffing and Management Plan (see E. 5.

3) ................................................................................ 55 D. 4.

4. Institutional Capability and Experience (see E. 5.

4) ..................................................................... 62 D. 4.

5 Annexes: ..................................................................................................................................... 63 D. 5 SELECTION OF APPARENTLY SUCCESSFUL APPLICANT ...................................................................................

64 D. 5. 1 PHASE II: Pre-award Co-design and Full Application ..................................................................

64 D. 6 BUSINESS (C OST ) APPLICATION ............................................................................................................... 65 D.

6. 1 Cost Application Requirements ................................................................................................... 66 D.

6. 2 Cover Page .................................................................................................................................. 66 D.

6. 3 Standard Form (SF) 424 .............................................................................................................. 66 D.

6. 4 Budget And Budget Narrative ..................................................................................................... 67 > D.

6. 4. 1 SUMMARY BUDGET .........................................................................................................................

67 > D. 6. 4.

2 DETAILED BUDGET ........................................................................................................................... 67 > D. 6.

4. 3 COST APPLICATION FORMAT ........................................................................................................... 79 > D.

6. 4. 4 COST PRINCIPLES .............................................................................................................................

79 D. 6. 5 Prior Approvals In Accordance With 2 Cfr 200.

407 ..................................................................... 79 D. 6.

6 Approval Of Subawards (If Applicable) ....................................................................................... 80 D. 6.

8 Funding Restrictions: .................................................................................................................. 81 D. 6.

9 Unique Entity Identifier and System For Award Management (Sam) – Requirements ............... 81 D. 6.

10 Pre-Award Certifications, Assurances, Representations, And Other Statements of The Recipient and Pre-Award Terms ............................................................................................................................... 82 D. 6.

11 Branding Strategy and Marking Plan ..................................................................................... 82 A. Branding Strategy – Assistance (June 2012) ....................................................................................

83 B. Marking Strategy – Assistance (June 2012) ..................................................................................... 84 D.

6. 12 Conflict of Interest Pre-Award Term (August 2018) ............................................................... 87 D.

6. 13 Cost Application Review ......................................................................................................... 87 SECTION E: APPLICATION REVIEW INFORMATION ......................................................................................

89 E. 1. CRITERIA .............................................................................................................................................

89 E. 2. REVIEW AND SELECTION P ROCESS ............................................................................................................

89 E. 3. M ERIT REVIEW CRITERION .....................................................................................................................

89 E. 5. 1 Merit Review Criterion 1: Technical Approach (see D.

4. 1) .......................................................... 90 E.

5. 2 Merit Review Criteria 2: Learning, Monitoring, And Evaluation (LME) Plan (see D. 4.

2) ............. 91 E. 5.

3 Merit Review Criteria 3: Staffing and Management Plan (see D. 4. 3) .........................................

92 E. 5. 4 Merit Review Criteria 4: Institutional Capability and Experience (see D.

4. 4) ............................. 92 E.

4. E VALUATION OF COST APPLICATION ......................................................................................................... 94 E.

5. FULL APPLICATION ................................................................................................................................ 94 SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION ...............................................................

95 F. 1. FEDERAL AWARD N OTICES .....................................................................................................................

95 F. 2. ADMINISTRATIVE & N ATIONAL P OLICY REQUIREMENTS ...............................................................................

95 F. 3. REPORTING REQUIREMENTS ...................................................................................................................

95 F. 3. 1.

Financial Reporting ..................................................................................................................... 95 F. 3.

2. Activity Planning ......................................................................................................................... 96 F.

3. 3. Implementation Plans ...............................................................................................................

101 F. 4. P ERFORMANCE REPORTING ..................................................................................................................

102 F. 4. 1.

Biweekly Update ....................................................................................................................... 102 F. 4.

2. Quarterly Report ....................................................................................................................... 102 F.

4. 3. Annual Performance Reports ....................................................................................................

104 F. 4. 4.

High Frequency Report (HFR) .................................................................................................... 105 F. 4.

5. Close out Plan ........................................................................................................................... 105 F.

5. FINAL P ERFORMANCE REPORT .............................................................................................................. 105 F.

6. E NVIRONMENTAL COMPLIANCE ............................................................................................................. 107 F.

7. CLIMATE RISK .................................................................................................................................... 108 Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity F.

8. P ROGRAM I NCOME ............................................................................................................................. 109 F.

9. O THER REQUIREMENTS ....................................................................................................................... 109 SECTION G: FEDERAL AWARDING AGENCY CONTACT(S) ...........................................................................

110 G. 1. P OINTS OF CONTACT (POC): .......................................................................................................................

110 G. 2. THE AGREEMENT O FFICER REPRESENTATIVE (AOR): .......................................................................................

110 G. 3. DIFFERENT CONTACTS FOR DISTINCT KINDS OF HELP :..................................................................................

110 SECTION H: OTHER INFORMATION ............................................................................................................ 111 ANNEX 1 – BUDGET FORMATS .......................................................................................................................... 112 ANNEX 2 - P AST P ERFORMANCE I NFORMATION (PPI) ............................................................................................

116 ANNEX 3 - STANDARD P ROVISIONS ....................................................................................................................

117 REQUIRED AS APPLICABLE STANDARD PROVISIONS FOR U.S. NONGOVERNMENTAL ORGANIZATIONS 117 REQUIRED AS APPLICABLE STANDARD PROVISIONS FOR NON-U.S. NONGOVERNMENTAL ORGANIZATIONS ................................................................................................................................................................

119 ANNEX 3 - LIST OF SUPPLEMENTAL DOCUMENTS .....................................................................................

121 Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity ADS Automated Directives System AOR Agreement Officer’s Representative CBHI Community Based Health Insurance CHD Child Health and Development CHU Community Health Unit CDCS Country Development and Cooperation Strategy CLA Collaboration, Learning and Adaptation CQI Continuous Quality Improvement CRM Climate Risk Management DIS Development Information Solution ECBH Empowered Communities for Better Health EDHS Ethiopia Demographic and Health Survey EFY Ethiopian Fiscal Year EHCRIG Ethiopia Health Center Reform Implementation Guideline EHSTG Ethiopia Hospital Services Transformation Guideline EmONC Emergency Obstetric and Newborn Care FGM Female Genital Mutilation GBV Gender-Based Violence GIS Geographic Information System GoE Government of Ethiopia HMIS Health Management Information System HSS Health Systems Strengthening HSTP Health Sector Transformation Plan HTP Harmful Traditional Practice IPC Infection Prevention and Practice KPI Key Performance Indicator Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity LME Learning, Monitoring and Evaluation LMG Leadership, Management and Governance MNCH Maternal, Newborn, and Child Health NPI New Partners Initiative PHCU Primary Health Care Unit PPR Performance Plan and Report RBF Results -based financing RHB Regional Health Bureau RiPAs Resilience in Pastoralist Areas RMNCH Reproductive, Maternal, Newborn, and Child Health RMNCAH -N Reproductive, Maternal, Newborn, Child and Adolescent & Youth Health and Nutrition SBA Skilled Birth Attendance SBC Social and Behavior Change SGBV Sexual and Gender -Based Violence SNNP Southern Nations, Nationalities and Peoples STTA Short -Term Technical Assistance THDR Transform Health in Developing Regions UNDP United Nations Development Program USG United States Government WASH Water, Sanitation and Hygiene WDA Women Development Army WMS Woreda Management Standard ZHD Zonal Health Department Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity SECTION A: PROGRAM DESCRIPTION USAID Lowlands Health Activity Purpose: USAID/Ethiopia intends to award a five-year assistance Activity, entitled USAID Lowlands Health, to support an organization or a group of organizations, from here on known as “Recipient” or “Consortium”, who share the expressed public purpose of improving health and nutrition outcomes in the pastoral geographies of Ethiopia, through increased access and utilization of quality reproductive, maternal, newborn, child, and adolescent & youth health and nutrition (RMNCAH-N) services.

Period of Performance and Funding: USAID/Ethiopia expects to award one (1) cooperative agreement based on a competitive Notice of Funding Opportunity. Subject to the availability of funds, USAID/Ethiopia intends to allocate up to $35 million over a five (5) year period. USAID reserves the right to fund any or none of the applications submitted.

If an award is made, it will be funded with maternal and child health and family planning (FP) funding. Therefore, all proposed activities and interventions should directly contribute to improved RMNCAH-N services uptake, and ultimately, improved RMNCAH-N outcomes for citizens in the targeted geographic areas.

Geographic Focus: The USAID Lowlands Health Activity will operate in 35 selected districts across the Afar and Somali Regions and Borena Zone of the Oromia and South Omo Zone of Southern Nations, Nationalities and People’s (SNNP) Regions.

The Activity will have a significant focus and engagement at the woreda (i.e., district) level supporting the strengthening of the primary health care (PHC) facilities and their respective administrative structures. It is expected that this Activity will coordinate with the Ministry of Health (MoH), the respective Regional Health Bureaus (RHB), and Zonal Health Departments (ZHD).

This Activity will have significant engagement at the PHC level to improve quality and utilization of RMNCAH-N services, while ensuring that communities are effectively engaged to improve their own health.

The Activity will have 100% coverage within a woreda, albeit interventions will not be uniform and will instead be tailored based on a jointly planned implementing partner, USAID, and MoH assessment and prioritization process that will identify and inform a data-driven, tailored technical assistance plan at each facility.

Institutional Linkage, Partnership and Coordination: The USAID Lowlands Health Activity will contribute to USAID/Ethiopia’s Development Objective (DO) 4: “Sustained improvement in essential service delivery outcomes, focused on women and girls” of USAID/Ethiopia’s 2019-2024 Country Development Cooperation Strategy (CDCS). Specifically, the Activity will contribute to Intermediate Results (IR) 4.

4: “Utilization of quality health and nutrition services increased,” and IR 4. 5: “Health and nutrition systems strengthen for greater self-reliance”. The Activity is within the Empowered Communities for Better Health (ECBH) Project and contributes to its three results, namely (1) adoption of health and nutrition behaviors, (2) improved accountability and responsiveness, and (3) enhanced quality of services.

The Activity will build on USAID/Ethiopia’s prior and existing investments in RMNCAH-N, including the Transform Health in Developing Regions (THDR) and Transform Primary Health Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity Care (TPHC) awards.

To the extent possible and for the greatest impact, this Activity will maximize coordination, integration and geographic overlap with other relevant USAID/Ethiopia activities, including the Lowlands Resilience in Pastoral Areas (RiPA) Activities and the Climate Resilient Water, Sanitation and Hygiene (CR-WASH) Activity.

Coordination may include joint annual implementation plan development, coordinated implementation when possible, resource leveraging where cost-effective and impactful, and joint results reporting to USAID/Ethiopia. To the extent possible and towards maximizing cost-efficiencies, the Recipient will explore co-location with another USG activity in establishing a greater regional presence and a smaller Addis Ababa Office.

Furthermore, the Activity is in line with and should contribute to the quality and equity transformation agenda and priorities of the Government of Ethiopia (GoE), as outlined in the second Health Sector Transformation Plan (HSTP II 2020-2025 ), the Health Extension Program (HEP) Roadmap (2020-2035), the Strategy (2020/21 – 2024/25), the National Healthcare Quality and Safety Strategy, and the Pastoral Development Policy and Strategy .

Selection and Co-design Process: The selection and co-design process for this Activity will include: 1) Oral presentations in Addis Ababa or virtually for all applications that are in compliance with the directions of submission within this solicitation, and 2) Based on the oral presentations, Apparently Successful Applicant(s) will be invited to a pre-award codesign meeting with USAID/Ethiopia.

Then the Apparently Successful Applicant(s) will submit a full program description (PD) inline with the pre-award co-design meeting. A post-award planning workshop will occur to refine the interventions of the Activity with USAID/Ethiopia and other relevant actors.

During this planning workshop, the intervention packages, metrics to monitor change, and partnership expectations (including co-financing), informed by inputs from the MoH and the respective RHBs and by a thorough review of relevant data for woreda selection (Attachment 2) will be refined.

Note that this Activity will not provide direct financial and/or material support (i.e., direct subgrants) to public international organizations or to GoE entities, including regional and woreda health offices, parastatals, or affiliated universities, and will instead establish co-financing agreements to ensure commitment and funding realization at regional and woreda levels to support PHC services at facility level.

Potential exceptions will only be considered for select high-performing health facilities to receive results-based financing (RBF) grants as noted in Section 6. 3. High, medium, and low performing woredas will be selected to ensure cross-collaboration and learning through experience-sharing among the woredas.

Post-award regional co-planning workshops will be conducted to tailor the assessment process and subsequent interventions to the specific regional and community contexts. All decisions during these co-design processes will be based on cost-efficiencies, data/evidence, and budget considerations to drive improved performance and health and nutrition outcomes in selected intervention areas.

Expanded access to improved quality and utilization of health and nutrition services are required to improve health and nutrition outcomes and key development indicators in the pastoral areas of Ethiopia. Therefore, the goal of the USAID Lowlands Health Activity is to improve health and nutrition outcomes in the pastoral areas by increasing access, quality, and utilization of health and nutrition services.

USAID/Ethiopia aims to partner across sectors with key Ethiopian stakeholders, other development partners, private sector entities, civil society Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity organizations, local universities, and/or professional associations in working towards this vision.

The Activity goal will be achieved through four key, interrelated objectives: Enhancing PHC facility governance, leadership, and functionality to deliver essential services Improving access to and quality of services through client-centered and contextualized service delivery models Increasing adoption of healthy behaviors including utilization of services Rehabilitating/renovating health facilities to provide essential RMNCAH-N services Additional details on the objectives and expected results are outlined in Section Five (5), Activity Description.

Ethiopia is home to over 80 ethnic groups with diverse cultural, religious, and linguistic backgrounds. As of 2021, Ethiopia had an estimated population of more than 120 million, of which over 78 percent reside in rural areas. While Ethiopia is Africa’s second most populous country and one of the fastest growing economies in Africa, it still ranks as one of the poorest, with a per capita income of $925.

The northern conflict that started in November 2020 and the different ethnic-based tension that has been happening throughout the country has impacted Ethiopia’s progress. The country has eleven regional states and two chartered city administrations that are further divided into zones/sub-cities, districts, and kebeles (administrative villages).

For regional states, the woreda is the lowest independent administrative unit that contains several rural kebeles. Ethiopia’s health sector is decentralized, with the woreda managing the primary health care units (PHCU) and the bulk of public health programs at community and household levels.

Ethiopia’s Health Service Delivery Context: Ethiopia’s 1993 Health Policy continues to provide the health system framework in emphasizing comprehensive primary health care (PHC), including disease prevention, health promotion, and rehabilitating disabilities. The policy also mandates that the MoH develop health infrastructure, health workforce, and service delivery systems.

The fourth Health Sector Development Plan (2010/11-2014/15) introduced a three-tier health care delivery system: primary, secondary and tertiary. As opposed to the earlier six-tier or four-tier health care delivery arrangements, the three-tier system brought the primary health services closer to the communities and households.

There is a slight difference in primary health care delivery arrangements between the urban and rural areas, as depicted in the diagram below. Over 90% of the health services are provided by the public health system in rural settings. Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity The PHC level consists of a primary hospital, catchment health centers (HC), and satellite health posts (HP).

At this level, the majority of community health interventions are delivered through the HEP. Secondary care is delivered by general hospitals with a catchment population of 1. 5 million and overseen by a RHB.

On the other hand, tertiary care is provided by specialized hospitals with a catchment population of approximately five million people with federal and regional oversight. Ethiopia’s Health System Performance: Ethiopia’s Demographic and Health Surveys (EDHS) show overall positive trends over the past 20 years, though not at the rates required to meet the country’s HSTPs and the Sustainable Development Goals.

From 2000 to 2016, the maternal mortality ratio declined by 53 percent to 412 per 100,000 live births. Per the 2019 mini-EDHS, modern contraceptive use among currently married women increased (since the 2005 EDHS), from 14% to 41%, and under-five mortality rate and stunting decreased by 52 percent and 28 percent (since the 2005 EDHS) to 59 per 1000 live births and to 37 percent of under-five children, respectively.

The neonatal mortality rate decreased by 33 percent (since the 2000 EDHS) to 33 per 1000 live births. The 2016 emergency obstetric and newborn care (EmONC) survey showed an institutional stillbirth rate (SBR) of 13. 9, while the 2020 Interagency Group for Child Mortality Estimation estimates the SBR to be 24 for Ethiopia - nearly double the global and national Every Newborn Action Plan target.

In all, Ethiopia has made much progress in key health indicators. Progress is largely attributed to the GoE’s commitment to enact health and development policies and an increase in health information and services, especially through its HEP; however, the country has yet to sustainably improve the health status of all its citizens, as shown by the significant disparities across regions and especially for pastoralist subpopulations.

Ethiopia’s Pastoral Geographic and Health Context: Pastoralists represent 12 percent of Ethiopia’s population (approximately 14 million people) and occupy 60 percent of arid and semiarid areas of the country. Pastoralists and agro-pastoralists reside in the Afar and Somali Regions and in some zones of the Oromia and SNNP Regions.

Although common climatic, social, and economic features are shared by many of the pastoral areas, these communities are not homogenous. As per the 2017 baseline for the USAID Regional Pastoral Livelihoods Resilience Activity, pure pastoralists are only common in the Afar (51 percent) and Somali Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity Regions (36 percent).

While a quarter of pastoralists in the Afar and SNNP Regions and 35 percent in Oromia Region are not mobile, they do own livestock and reside in areas characterized as pastoral. Such differences are critical in designing appropriate health service delivery modalities (mobile and static) to meet the varying needs of subpopulations in pastoral areas. The health system in the pastoral geographies is challenged by several factors.

Pastoralist and agropastoralist communities have limited access to infrastructure, including roads, electricity, telecommunication, clean water sources, and health services. Recurrent disease outbreaks (human and animal outbreaks commonly happen twice per year) and other shocks (e.g., flooding, drought, chronic ethnic and/or political conflicts, etc.) lead to internal displacement that results in poor health and nutrition outcomes.

Additionally, there is poor multi-sectoral and intersectoral collaboration, and to-date, the HEP has lacked proper contextualization and rollout to pastoral settings, resulting in poor performance. The available health and nutrition services are frequently not culturally-appropriate or accessible to remote or mobile populations, which contributes to the relatively low prevalence of consistent health-seeking behaviors.

The 2016 EDHS and 2019 mini-DHS data clearly highlight the gross health inequities between pastoral and non-pastoral regions. The Afar and Somali Regions perform lower than the national average on all reproductive, maternal, newborn, and child health (RMNCH) metrics (See Table 1 below). 3 The 2016 EmONC survey demonstrated similar inequities in that the Afar and Somali Regions fell below the national average of met need for EmONC.

Cesarean section rates in Ethiopia are well below the expected range of 5-15 percent, with the lowest rates in the Afar and Somali Regions at less than 1 percent. The Afar and Somali Regions had stillbirth rates (SBR) of over 20 per 1000 births, while the national SBR was 13. 9 per 1000 births.

Kangaroo mother care initiation, a life-saving intervention for low birthweight babies, was recorded for less than 1 percent for the Afar Region and only 2 percent of eligible babies in the Somali Region. Newborn resuscitation with a bag and mask demonstrated a similar pattern in these regions. These national surveys do not demonstrate the differences between pastoral and non-pastoral populations living in the Oromia and SNNP Regions.

However, health management information system (HMIS) reports show that the pastoral woredas of the SNNP and Oromia Regions have a cumulative higher achievement in most RMNCH indicators than the pastoralist regions (Afar and Somali).

Table 1: Status of Selected RMNCH Indicators by Region (Source: Mini-DHS 2019) > Vaccination (All Basic Vaccines) > Amhara 50% 51% 54% 40% 62% > Gambella 34% 32% 70% 55% 38% > Oromia 41% 41% 41% 26% 30% Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity > SNNPR 45% 34% 48% 32% 67% > Tigray 37% 64% 72% 63% 73% > Afar 13% 31% 28% 23% 20% > Somali 3.

4% 11% 23% 10% 19% > National 41% 43% 48% 48% 65% The Afar Region covers an area of about 72,053 sq km with an estimated population of 2 million, most of whom are pastoralist and agro-pastoralist and predominantly Muslim. The region is administratively divided into six zones and has 40 woredas. For health services, the region has nine hospitals (two of which are private), 96 HCs, and 338 HPs.

The Afar Region was severely impacted by the northern Ethiopia conflict that started in November 2020, including looting and damage of health facilities and other critical infrastructure. The northern conflict has affected all zones of the Afar Region, except Zone 3.

Based on an internal USAID/Ethiopia assessment conducted in June 2022, 41 health facilities (one hospital, 12 HCs and 28 HPs) within seven woredas in the Afar Region were damaged by the conflict. As a result, the communities in these conflict-affected areas have limited access to essential health services.

Additionally, the region’s health system and residents have dealt with compounded shocks, including recurrent flooding, COVID-19, and various disease outbreaks (i.e., cholera, measles, etc.), over the last several years. As of August 30, 2022, the Regional Disaster Risk Management and Food Security Commission estimated that 1.

4 million people are in need of humanitarian assistance, due to the compounded effects of conflict, drought, and floods. Despite several humanitarian and development actors currently providing support to the region, there has been a persistent lack of strong coordination and comprehensive documentation outlining all partner contributions and outstanding gaps.

Therefore, concerted effort will be required to restore health services in this fragile context to pre-conflict status, including delivery of quality RMNCAH-N services, including agile and adaptive programming.

To achieve this objective, USAID/Ethiopia seeks focused, innovative approaches to refine its health programming by gathering real-time evidence and by soliciting partnerships with traditional and non-traditional organizations working to strengthen RMNCAH-N outcomes in the Afar Region.

The Somali Region covers an area of about 328,068 sq km with an estimated population of 6 million, most of whom are pastoralist and agro-pastoralist and predominantly Muslim. The region is administratively divided into 11 zones and has 104 woredas. For health services, the region has 12 hospitals, 208 HCs, and 1214 HPs.

Recent and historic drought in the Somali Region have impacted the availability, coverage, and quality of health and nutrition services in these pastoralist regions. A recent assessment by the Somali Regional State Disaster Risk Management Bureau showed that severe acute malnutrition (SAM) admission increased by 37 percent compared to previous year of the same period.

An estimated 22 million people are in need of emergency food assistance in Ethiopia Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity due to conflict, drought, and floods (OCHA). All drought-affected woredas in the Somali Region showed a high prevalence of global proxy acute malnutrition of over 15 percent.

According to UNICEF, from January to June, 2022, SAM admissions with medical complications increased by 57 percent in the Somali Region, compared to the same period last year. The drought associated malnutrition coupled with displacement is increasing the risk of disease and death in the affected communities.

In the Somali Region, a measles outbreak, with 2,104 cases reported, and maternal deaths were recorded in the highest number (32% of the national report) since January, 2022. (EPHI epi week 33 report).

Factors contributing to a high number of cases of acute malnutrition and preventable deaths include overburdened health facilities, lack of sanitation and safe drinking water, limited content and frequency of food aid, and the upsurge of measles and other communicable diseases due to cross-border Pastoral woredas of Oromia and SNNP Regions The Borena and South Omo zones are the largest pastoralist populated areas in Oromia and SNNP Regions respectively.

As the settlement of the population is very sparse in the Borena zone, it is hard for many villagers to access health facilities in most places. The Borena is one of two major subgroups of the Oromo people. Unlike other pastoralist areas, the Borena has organized women development armies (WDA).

The Borena and South Omo have strong traditional structures such as Abba Olla (Borena) and Balabat (South Omo) that influence any community actions including community health issues. Like the other pastoral areas in Afar and Somali Regions, the Borena and South Omo zones are affected by recurrent conflict, shocks and public health emergencies.

15 Ethiopia’s Pastoral Health Improvement Efforts: In 2018, the GoE published the Strategy for Revitalizing Health Extension Program for Pastoralist Areas with the goal to “narrow the prevailing gaps on key health outcomes between pastoralist regions and national average.

” While the strategy was ambitious, the disparities in uptake of services depicted in Table 1 still remain, and much more needs to be done to reach the pastoralist areas. The USAID Transform Health in Developing Regions Activity’s (THDR) 2020 mid-term evaluation demonstrated that if appropriate interventions are implemented, health indicators in pastoral geographies can be significantly improved over time.

However, most of these improvements were negatively impacted by the conflict and drought that affected these regions, as documented in THDR’s 2022 final evaluation. For instance, in the Afar Region, early ANC utilization increased from 16 to 36 percent by 2020, which then declined to 12 percent in 2022.

In the Somali Region, full childhood immunization increased from 20 to 26 percent during the midterm, as compared to THDR’s 2017 baseline, and dropped to 3 percent in the 2022 final evaluation.

On the positive side, the final evaluation also showed that the reduction at the endline was higher in the control sites, when compared to the THDR intervention sites, denoting the significance of the Activity in preventing further deterioration of key health indicators.

This USAID Lowlands Health Activity will build upon such lessons to sustain and advance USAID and other investments in pastoral geographies for improved health and nutrition outcomes. Pastoral communities in Ethiopia have sustained poor social development outcomes relative to their agrarian and urban counterparts.

The health needs of pastoral communities have Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity been historically neglected, and/or the available health and nutrition services have lacked proper contextualization to the pastoral setting.

In the past, the GoE advocated for pastoral communities to stay settled in specific locations to enable a static site service delivery model, which does not adequately address the health needs of mobile populations in pastoral areas. Overall, gross inequities still remain in pastoral areas in terms of access to and utilization of high-quality services, resulting in poor RMNCAH-N outcomes.

Barriers to the Utilization of Quality Health and Nutrition Services in Pastoral Communities: Distance and Geographic Access : Geographic factors, including distance and poor road conditions, as well as limited operational capacity for service delivery and population tracking (See attachment 3 for more information on mobility of pastoral communities), hinder utilization of health and nutrition services.

The health facilities in these areas lack data on seasonal migration and temporary camp locations and have limited capacity to adapt delivery strategies, which compromise RMNCAH-N service delivery and access.

Health Care Cost to Clients: Cost to clients includes direct medical costs (i.e., out-of-pocket, informal fees, medicines, etc.), non-medical costs (e.g., transport), and indirect costs/opportunity costs (e.g., loss of income due to lost workdays) compounded by household vulnerability to catastrophic health shocks amidst other climatic events.

While the GoE has attempted to address financial barriers in increasing access to certain RMNCAH-N services through fee exemptions, community-based health insurance (CBHI) has not been scaled up widely in the pastoral areas exacerbating the out-of-pocket expenditures. Only three (3) woredas of the Afar Region and four (4) woredas of the Somali Region started CBHI implementation.

This Activity will not directly support health care financing activities, including CBHI, and will instead coordinate and leverage other USG and non-USG resources to advance this initiative. Health Facility Service Readiness : Available resources for financing the health system in the pastoral regions have been small, with other priorities limiting availability and delivery of quality health and nutrition services.

For instance, only 10% and 14% of government expenditure is spent on health in the Somali and Afar Region respectively in 2014 EFY (2021/2022) 26 .

As a result, facility readiness is suboptimal in the pastoral regions given the lack of infrastructure and basic amenities (e.g., clean water, electricity, telecommunications, etc.), consistent availability of essential medicines, diagnostic capacity, standard infection prevention and control (IPC) protocols, and competent healthcare workers (HCW).

For example, in 2018 only 68% of health facilities that provide comprehensive obstetric care services had tracer items in the Afar and Somali Regions while only 38% and 52% of health facilities had basic amenities tracer items in the Somali and Afar Regions respectively.

Quality of Health Services: Improving the quality of health services is key to increasing service uptake and ultimately bringing about better health and nutrition outcomes.

The quality of PHC delivery in the pastoral areas is affected by several constraints, including poor leadership, management and governance (LMG) practices, shortage of medicines and supplies, lack of competent and motivated HCWs, and suboptimal performance monitoring and accountability systems. 20 The doctor to population ratio is 1:11,685 and 1:9,512 in the Afar and Somali Regions respectively.

As per the 2019 Ethiopia Health market labor analysis, 55% and 65% of health workers are males in the Afar and Somali Region respectively. Besides, the number of Notice of Funding Opportunity No. 72066323RFA00007; USAID/Ethiopia Lowland Health Activity women in leadership positions is much lower than males. Only 31% and 47% of health facilities that provide ANC services have the ANC tracer items in the Somali