Issue Date: September 12, 2024

Deadline for Questions: September 20, 2024; 5:00 p.m. India Local Time
(Response to questions will be provided through an amendment to NOFO at
[Link]
Closing Date and Time: October 29, 2024; 5:00 p.m. India Local Time

Subject: Notice of Funding Opportunity (NOFO):72038624RFA00004

Program Title: Health Systems Strengthening (HSS) Activity

Federal Assistance Listing Number: 98.001

All Interested Parties,

The United States Agency for International Development (USAID/India) is seeking concept papers
for a Fixed Amount Cooperative Agreement from qualified entities to implement the “Health Systems
Strengthening (HSS) Activity.” Eligibility is open to all U.S., local, and international non-
governmental organizations.

USAID intends to make an award to the applicant(s) who best meets the objectives of this funding
opportunity based on the merit review criteria described in this NOFO, subject to a risk assessment.
Eligible parties interested in submitting a concept paper are encouraged to read this NOFO thoroughly
to understand the type of program sought, submission requirements and the selection process.

To be eligible for award, the applicant must provide all information as required in this NOFO and
meet eligibility standards in Section C of this NOFO. This funding opportunity is posted on
[Link], and may be amended. It is the responsibility of the applicant to regularly check the
website to ensure they have the latest information pertaining to this notice of funding opportunity and
to ensure that the NOFO has been received from the internet in its entirety. USAID bears no
responsibility for data errors resulting from transmission or conversion process. If you have difficulty
registering on [Link] or accessing the NOFO, please contact the [Link] Helpdesk at 1-
800-518-4726 or via email at support@[Link] for technical assistance.

USAID may not award to an applicant unless the applicant has complied with all applicable unique
entity identifier and System for Award Management (SAM) requirements detailed in Section D. The
registration process may take many weeks to complete. Therefore, applicants are encouraged to begin
registration early in the process.

Issuance of this notice of funding opportunity 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, concept paper or an application. Concept Papers are
submitted at the risk of the applicant. All preparation and submission costs are at the applicant’s
 NOFO No: 72038624RFA00004: Health Systems
Strengthening (HSS) Activity

expense.

Please send any questions to the point of contact identified in Section D. The deadline for the
questions is shown above.

Thank you for your interest in USAID programs.

Sincerely,

Cheryl Hodge- Digitally signed by Cheryl

Hodge-Snead

Snead Date: 2024.09.11 19:06:28

+05'30'

Cheryl Hodge-Snead
Agreement Officer
USAID/India

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TABLE OF CONTENTS

SECTION A – PROGRAM DESCRIPTION

SECTION B – FEDERAL AWARD INFORMATION

SECTION C – ELIGIBILITY INFORMATION

SECTION D – CONCEPT PAPER SUBMISSION INFORMATION

SECTION E – CONCEPT PAPER REVIEW INFORMATION

SECTION F – FEDERAL AWARD ADMINISTRATION INFORMATION

SECTION G – FEDERAL AWARDING AGENCY CONTACTS

SECTION H – OTHER INFORMATION

ANNEXURES:

1. STANDARD PROVISIONS
2. PRELIMINARY GENDER EQUALITY AND SOCIAL INCLUSION ANALYSIS.

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SECTION A: PROGRAM DESCRIPTION

END OF SECTION A

1. Program Framework

Purpose

India’s growth, dynamism and human capital provides unique opportunities for USAID
engagement, unlike those found anywhere else in the world. It provides the agency with a roadmap
of how to transition health programming in emerging economies, especially in ecologically fragile
subregions, whilst continuing to promote the agency priorities of diversity, equity and inclusion,
localization, using technology responsibly and engaging the private sector for development
objectives.

This Health Systems Strengthening (HSS) activity aims to transform USAID’s traditional assistance
to the Government of India (GoI) on cross-cutting health systems strengthening, signaling the
transition in the US India partnership in health by strengthening platforms and institutions in the
public and private sector to accelerate and scale innovative development approaches that are
inclusive, sustainable and leverage digital health technologies. The purpose of the activity is to
accelerate and scale up, and not incubate and seed, innovative approaches to increasing access and
reducing out-of-pocket expenditure on healthcare in India. This activity will focus on vulnerable
and marginalized communities in India, including those in urban areas, with the aim of expanding
equitable access to comprehensive primary healthcare, strengthening the continuum of care, and
advancing progress towards universal health coverage. This acceleration of innovative models and
approaches, especially in the private sector, will be assisted by risk underwriting from the US
International Development Finance Corporation (DFC) and other bilateral/multilateral financial
institutions.

This activity will move away from traditional models of assistance and focus on building and
growing connections between government institutions and systems, existing platforms within the
private sector, and networks of nonprofit entities and community-based organizations. The activity
will also explore how experience and innovations from India can strengthen comprehensive primary
healthcare (CPHC) around the world, adopting a platforms-based approach to take Indian healthcare
innovations to other partner countries globally.

Problem Statement

In the post COVID-19 pandemic era, the central challenge, globally and in India, is ensuring
inclusive public and private health systems are resilient, inclusive, and responsive, particularly at
the foundational primary care level. The significant progress made towards the quality and reach of
health services over recent years experienced significant backsliding during the pandemic in all
areas exacerbating inequities. Over the coming years, climate related health challenges including
extreme weather events shifting patterns of disease epidemiology have the potential to further
curtail progress towards universal health coverage. Taken together, these demonstrate the need for a
resilient health system capable and resourced to address existing challenges while managing new

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predictable and unpredictable ones. The government of India has allocated significant resources to
improve health outcomes, but capacities of different states and municipal health authorities vary in
their ability to deliver on these expenditure and budget utilization commitments.

Public healthcare access and services have expanded via the suite of initiatives offered under GoI’s
Ayushman Bharat program. Nevertheless, there remain gaps in geographic coverage, ease of access
and acceptability especially by marginalized groups like tribal and LGBTQ communities, cost
coverage, quality of care, and the integration of care between primary care “health and wellness
centers” (HWC’s) and higher-level facilities. HWC’s are also limited in their ability to deliver care
for non-communicable diseases that are the major causes of mortality among people aged below 50
years, mental health services, and preventive care (i.e. “wellness” services) to the communities
which they serve. While the government rolls out the HWCs, they are looking at innovative models
and technical assistance on how to integrate lateral programs of services delivery, include wellness,
address mental health, and integrate community and environmental surveillance at the HWC level.
In urban areas, the government is actively looking for insights and understanding on how to address
urban healthcare needs including wellness more effectively particularly leveraging digital health
wherever feasible.

The private sector is significant in terms of health care delivery and health ecosystem. As compared
to the government health system of approximately $30 billion, the private healthcare market in
India is approximately $300 billion and at 16% growth per year, is the fastest growing segment.
This private health sector also reaches out globally in terms of pharma, health tech, and
manufacturing, while looking to expand into education and human resources for health (HRH). On
the other hand, despite the global reach of the Indian private health sector, the consumer of
healthcare domestically still struggles to get affordable and quality healthcare, particularly those
that are vulnerable and marginalized.

Key Challenges

(a) The lasting effects of the pandemic on the health system

Given the global disruptions brought about by the COVID-19 pandemic, governments and investors
have renewed their focus and investments in pandemic preparedness and response capacities. But
this will be insufficient without sufficient focus on strengthening health systems and achieving
universal health coverage1. During COVID-19, countries with robust primary healthcare systems
saw minimal disruptions to other essential healthcare services2.

The disruptions caused by the pandemic resulted in an over 37% decline in hospitalizations in India
and an almost doubling of out-of-pocket expenditure, despite having the world’s largest
government funded health insurance program3. Primary healthcare was also severely impacted with
most of the districts in India witnessing more than 50% decrease in antenatal care and child

1
Woodcock, A., Coronavirus: Boris Johnson calls for global pandemic early warning system. The Independent, Sept
26, 2020.
2
Blanc DC, Grundy J, Sodha SV, et al. Immunization programs to support primary health care and achieve universal
health coverage. Vaccine. 2022
3
Garg S, Bebarta KK, Tripathi N. Household expenditure on non-Covid hospitalisation care during the Covid-19
pandemic and the role of financial protection policies in India. Arch Public Health. 2022;80(1):108.

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immunization4. The estimates of excess deaths due to the pandemic in India varies from 2.8 to 5.2
million 5as estimated by the National Library of Medicine, and between 3.71 to 4.36 million as
estimated by Lancet6. Most of these deaths occurred among people with comorbidities, especially
with chronic and NCD conditions. Another paper found COVID-19 mortality not only among the
elderly ages, but also identified a high impact of COVID-19 on the working population7. As the
health system was overwhelmed by COVID-19 patients, it became difficult for other patients with
acute or chronic ailments to access health services. Vulnerability was exacerbated, especially for
women, children, the elderly (particularly with NCDs) and those with special needs8. All this calls
for health systems strengthening with comprehensive primary healthcare linked with secondary and
tertiary care through a seamless continuum of care, especially focused on reducing under-50
mortality in India.

(b) Shifting disease and demographics

Within noncommunicable diseases, mental health has emerged as a major concern with stress,
anxiety, depression, insomnia, denial, anger and fear reported by people with existing mental
illness, frontline workers, older people and also children9 and we are seeing links with mental
health and traditional PHC treated conditions like MNCH, TB, HIV, reproductive health etc. Policy
makers at the national and state levels as well as both government and private healthcare providers,
both government and private, have strongly expressed the need to integrate care for mental health
and other noncommunicable diseases across all levels of the health system10. In addition, with
expanding human settlements, environmental changes and changes to food ecosystems, there has
been a resurgence in infectious diseases originating from animals and birds. These challenges will
require a one health system approach to responding to both infectious and non-communicable
diseases.

India is now the world’s most populous country and the nation’s demographic structure is slowly
evolving. While the bulge in the working-age population is expected to last till 2055, the proportion
of the aging population in India is on the rise. As per the Longitudinal Ageing Study of India

4
Avula R, Nguyen PH, Ashok S, et al. Disruptions, restorations and adaptations to health and nutrition service
delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: an observational study.
PLoS One. 2022
5
Banaji, M. and Gupta, A., 2022. Estimates of pandemic excess mortality in India based on civil registration data.
PLOS Global Public Health, 2(12), p.e0000803.
6
Wang, H., Paulson, K.R., Pease, S.A., Watson, S., Comfort, H., Zheng, P., Aravkin, A.Y., Bisignano, C., Barber,
R.M., Alam, T. and Fuller, J.E., 2022. Estimating excess mortality due to the COVID-19 pandemic: a systematic
analysis of COVID-19-related mortality, 2020–21. The Lancet, 399(10334), pp.1513-1536.
7
Azarudeen MJ, Aroskar K, Kurup KK, Dikid T, Chauhan H, Jain SK, Singh SK. Comparing COVID-19 mortality
across selected states in India: The role of age structure. Clin Epidemiol Glob Health. 2021 Oct-Dec;12:100877. doi:
10.1016/[Link].2021.100877. Epub 2021 Oct 9. PMID: 34816056; PMCID: PMC8602842.
8
Khetrapal, S. and Bhatia, R., 2020. Impact of COVID-19 pandemic on health system & Sustainable Development
Goal 3. The Indian journal of medical research, 151(5), p.395.
9
Roy, A., Singh, A.K., Mishra, S., Chinnadurai, A., Mitra, A. and Bakshi, O., 2021. Mental health implications of
COVID-19 pandemic and its response in India. International Journal of Social Psychiatry, 67(5), pp.587-600.
10
As per stakeholder consultations carried out by the USAID design team and Health Office staff between July and
September 2023.

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(LASI), from an elderly population of 104 million in 2011, the number will increase to 319 million
by 2050.

(c) Challenges in urban health

Cities are the predominant mode of living in India. With continued urban growth, India will see
rising inequities across a wide range of social and health dimensions. While social determinants of
health are not uniquely urban, the size, density, diversity and complexity of India’s cities amplify
their effects. Addressing the unique conditions affecting vulnerable urban populations such as slum
communities, LGBTQ populations, and migrant and construction workers, and how those
conditions impede access to healthcare services offers the greatest promise for reducing morbidity,
mortality and disparities in health in urban areas and for improving the quality of life and well
being. Although urban areas have high concentrations of secondary and tertiary care facilities, the
primary healthcare, which is the bedrock of all healthcare, is fragmented and disorganized with
disjointed governance/accountability. Also, the private sector dominates the healthcare provisioning
in urban areas, which is costly, at secondary and tertiary level and largely informal at the primary
level, with questionable quality of care.

(d) The healthcare ecosystem’s ability to deliver

Fiscal constraints and differential capacity across the multi-tier government service delivery system
have led to gaps in service coverage for vulnerable and marginalized sections of rural and urban
India. Given these gaps, the variance in quality, cost and consumers of the private sector is
significant, often leading to high transaction costs and risk for reaching the last mile with affordable
services and products. This is where social enterprises have stepped in with their inclusive business
models (IBMs), but they too are limited in scale because of inadequate funding and constraints
posed by the legal environment11.

(e) Challenges to inclusivity

The barriers to accessing healthcare by vulnerable and marginalized populations also include non-
medical obstacles like security, logistics, communications and socio-cultural issues, which need to
be factored in the design of services and programs12. Also, special population groups have
differential needs for services and the way those services are delivered. This is especially true for
groups like LGBTQ, people living with HIV, coastal fishing communities, backyard farmers or
animal rearers, mining and tea garden population, tribals, mobile populations, informal settlement
dwellers, and differently abled groups13.

(f) Climate change and its effects on health and the healthcare ecosystem
Climate change intersects with health in many ways, including direct injury from climate mediated

11
Tinsley, E. and Agapitova, N., 2018. Reaching the last mile.
12
Osetek, J.D., 2018. The Last Mile: Removing Non-medical Obstacles in the Pursuit of Global Health Security
(Doctoral dissertation, George Mason University).
13
As per stakeholder consultations carried out by the USAID between July and September 2023.

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extreme weather events and indirect changes to the epidemiology of infectious diseases; disrupting
availability and access to quality services and medical products; and altering environmental and
social determinants of health. Thus, it is imperative to put ample emphasis on building “climate
smart” health systems (resilient to climate challenges and low carbon impact).

2. Theory Of Change

India’s G-20 presidency under the theme of ‘One Earth, One Family, One Future’ transformed
India’s posture as a significant player in a new world order. India now needs to ensure its steady
economic growth whilst continuing to create opportunities and platforms to share its innovations
and successes with the world. Unforeseen future shocks in health have the potential to undermine
this growth at an individual, community and systemic level. Despite the country transitioning into a
middle income country, low total health expenditure as percentage of GDP (less than 4% of GDP),
very low government health expenditure as percentage of GDP (a little over 1% of GDP) and
unchecked out of pocket expenditures (OOPE) on healthcare will compromise the continued
economic growth of the country and force significant populations to be excluded from the growth
trajectory. It is estimated that more than 50 million people fall into poverty because of high OOPE
on healthcare, mostly due to spending on outpatient care, which also reduces their access to quality
healthcare. Most people impacted by high OOPE belong to marginalized communities in vulnerable
circumstances. A WHO report noted that OOPE on health services in

India has important implications for poverty levels and trends in India. Existing literature for India
shows that OOP payments not only impoverish a large number of households, reduce access to
timely and good quality healthcare, but also deepen poverty among already poor households.

The intended impact of the activity is to reduce under-50 mortality in India through a resilient
health care system with the ability to provide universal health coverage. The activity will achieve
this by focussing on the outcome of improved access and reduced out-pocket-expenditure (OOPE)
on health care, especially for vulnerable and marginalized communities. The result-areas to achieve
this outcome will include (i) increased access to integrated primary healthcare and wellness for
marginalized groups including those in both rural and urban areas across their lifespan, (ii) assured
continuity of care within and between primary, secondary and tertiary healthcare services, (iii)
strengthened public-private integration to boost access, affordability and quality of care, (iv)
increased supply side efficiency and demand-side financial risk cover, especially for primary health
care, in public and private health systems, and (v) increased adaptation and mitigation of climate
and environmental shocks affecting the health system. The activity will partner with the
government, the private sector, civil society and community based organizations to assist them to
test and scale up models and approaches to achieve the stated goals. The activity will not undertake
routine service delivery, training and supervision functions, but rather will work with the
government and private institutions, systems and networks to strengthen them to undertake those

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functions effectively. In the process, this activity will also identify promising approaches,
technological solutions and business innovations that can lead to improved access and reduced
OOPE, and work with the government and private partners to absorb and scale those innovations.
Reducing OOPE on health will also drive the demand for healthcare and encourage supply chain
innovations that improve access and inclusivity, reduce costs and enhance quality.

The theory of change for this activity is shown in the diagram below, which will be reviewed
annually, and amended, if needed:

Impact
Under-50 mortality in India reduced

Outcome
A resilient health system provides universal health coverage to all

Goal
Improved access and reduced out-of-pocket expenditure (OOPE) on quality healthcare in

Result 1: Result 2: Result 3: Result 4: Result 5:

Increased Assured Strengthen Increased Increased

access to continuity ed public- supply side adaptation
integrated of care private efficiency and
primary within and integration and mitigation
healthcare between to boost demand- of climate
and primary, access, side and
Cross-cutting
Commu Governa ComponentsPrivate
Digital Innovati Accelera

Principles
Localiz Inclusiv Ecosys India- Progress

3. Partnering with other USAID projects

The HSS activity will work with ongoing and future USAID projects and activities, in the priority
geographies, for better coordination and synergies. This will provide the opportunity to build on the
HSS work done during the pandemic and harness the opportunities created by surges in innovation
and investments in health solutions, to make the health system better equipped to face known and
unknown challenges whilst sharing successes with the world.

Coordination with other USAID projects and activities will include, but is not limited to, the
following:

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● Building on the primary healthcare support to the government provided by the NISHTHA
project, especially in the northeastern and the central Indian states;
● Leveraging the network of secondary and tertiary health facilities, including laboratory
networks under the RISE and Global Health Security (GHS) projects;
● Developing synergies with the climate and health activity to be undertaken under two local
works activities;
● Working with USAID’s HIV projects to support the PLHIV community-led micro social
enterprises;
● Assisting scale up of innovations supported under TB, GHS, MCH and FP projects
including access to appropriate capital from financial market platforms like impact
investment platforms and the Social Stock Exchange;
● Leveraging the SAMRIDH blended finance arrangement to help scale business and
product solutions that can reduce OOPE on health and improve access to care, especially
for marginalized and vulnerable communities;
● Working with USAID’s TB and HIV projects to accelerate coverage of out-patient care and
comorbidities for TB and HIV patients.
● Developing synergies with USAID projects funded by Development Partnerships and
Innovations Office (DPIO) like the REVIVE project, and also programs on WASH,
Education, Energy, and Climate supported by the General Development Office (GDO).
● For taking some of the innovations globally, partnering with activities of USAID’s Indo-
Pacific Office (IPO).

4. Priority Geographies
As this activity will prioritize acceleration, scale-up and institutionalization of innovative
approaches, while leveraging public and private platforms and resources, it will build on innovative
approaches and platforms already being developed and tested by existing USAID projects.

Working with these existing USAID projects and activities will necessitate working in the
geographies where these activities are present. This will cover the northeastern states - particularly
Assam, the central Indian states of Odisha, Jharkhand, Madhya Pradesh, and Chhattisgarh, and
urban areas including tier-2 and tier-3 towns and mega urban conglomerates like Mumbai, Delhi
and Bengaluru. Prioritizing these geographies does not mean that the HSS activity should undertake
routine health systems activities in these states, but rather that it should source innovative
approaches showing promise in these states and leverage government and private sector institutions
and platforms to take them to scale regionally and nationally, while sharing relevant knowledge and
resources for how to scale these approaches with a global audience.

5. Outcome, Results and Key Deliverables

The activity will use a multidisciplinary approach to larger health ecosystem issues to identify, test
and scale tailormade climate resilient and adaptive healthcare models and approaches aimed at

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increased quality service uptake and reduced OOPE, especially for vulnerable and marginalized
communities across urban, rural, and tribal areas. Due to the multidisciplinary nature of the activity,
it will require multiple implementing partners, either as a consortium or as sub contracted agencies,
with specialized skill expertise across domains.

This activity will support healthcare delivery models, approaches and platforms that already exist
but need an additional nudge to transition to scale, either within government programs or as
sustainable inclusive business models. While a period of testing of approaches and models is
expected, the activity will mainly focus on bringing them to scale and developing the capacity of
the final adopter of the approaches and models (e.g. government, private sector, or the community)
to assume ownership.

Expected Impact, Outcome, Goal and Results:

The activity identifies the primary development challenge as a reduction in under-50 mortality
through a resilient health system that is able to deliver universal health coverage while responding
to emerging climate and health shocks. The reduction in under-50 mortality will be achieved by
helping build a resilient health system in India that is prepared for future climate and health
challenges, while accommodating the special needs of the vulnerable and marginalized population
segments in India. The purpose of the activity is to identify, test and scale up sustainable, easily
accessible, affordable and quality healthcare models through the institutions, platforms and
networks of the national and state governments, city administrations, private sector and community
based organizations. Through this, the activity aims at achieving the outcome of increased health
service uptake and reduced OOPE, especially for the vulnerable and marginalized groups.

The expected impact, outcomes, key results, and illustrative activities are given below.

Impact : Under-50 mortality in India reduced

Outcome: A resilient health system that provides universal health coverage
Goal: Improved access and reduced out-of-pocket on quality healthcare in India, especially for
vulnerable and marginalized communities

Result 1: Increased access to integrated primary healthcare and wellness for marginalized groups
including those in both rural and urban areas across their lifespan. (Level of effort - 30%)
Illustrative activities:
● Demonstrate and scale up innovative, comprehensive, quality primary healthcare models
and platforms, including networked care models, that reflect the needs of the variety of
users and suppliers of primary health care, including those that focus on digitization and
aggregation of services and processes.
● Expand public health surveillance for disease prevention and response by integrating

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environmental data, especially in urban areas within the primary healthcare system.

Result 2: Assured continuity of care within and between primary, secondary and tertiary healthcare
services (Level of effort - 20%)
Illustrative activities:
● Deploy innovative approaches (including digital technology) to boost quality, empower
both patients and health workers, and integrate care across the healthcare continuum.
● Leverage the network of public and private secondary and tertiary healthcare facilities,
including the network of laboratories.
● Demonstrate quality integrated health services including systems for infection prevention
and control and addressing AMR
● Building a resilient health system for pandemic preparedness such as surge capacities,
resilient supply chain, strengthening lab and emerging priorities of Government of India for
pandemic preparedness.

Result 3: Strengthen public-private integration to boost access, affordability and quality of care
(Level of effort - 20%)
Illustrative activities:
● Strengthen public-private integration to boost access, affordability, and quality of care (e.g
public-private partnership management, strategic purchasing etc), especially for “primary
impact collaboratives” and AMR alliances.
● Scale market based solutions, including support for commercial viability and market
shaping, to address persistent health challenges (e.g. social enterprises, inclusive/affordable
business models, etc.).
● Partnering with medical and business associations, CSR platforms, in collaboration with
local government, for primary healthcare collaborations focussed on leveraging resources
and innovations.
● Support ongoing platforms/efforts engaged in training and certification of private primary
care facilities and linkages to affordable drugs and diagnostics.

Result 4: Increased supply side efficiency and demand-side financial risk cover, especially for
primary health care, in public and private health systems. (Level of effort - 20%)
Illustrative activities:
● Include preventive and out-patient care in government and private health insurance
programs.
● Help integrate national health programs (like the HIV, TB, AMR program) in publicly
subsidized or privately financed insurance programs, including adoption of disease
management protocols and quality standards.
● Strengthen public financial management, especially the municipal finance and governance,
to finance comprehensive and integrated healthcare.

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● Support for resource mobilization, including risk underwriting by the Development Finance
Corporation, for public and private health systems from diverse and underutilized sources
(e.g. diaspora, social stock exchange, district mineral funds, municipal bonds, etc.)
● Leverage innovative platforms (like social stock exchange, GIFT city platform, social
impact bonds, multilateral blended finance platforms) to accelerate access and impact
towards integrated quality and affordable healthcare services.

Result 5: Increased adaptation and mitigation of climate and environmental shocks affecting the
health system (Level of effort - 10%)
Illustrative activities:
● Strengthen health facilities and healthcare supply chains to respond to climate and health
shock
● Scale up business models for healthcare waste management, renewable energy, green
health facilities and green supply chain in public and private health systems

For the above mentioned results, the planned deliverables of the activity are:

1. Integrated, high quality, and affordable, primary health care models, with assured
continuum of care, scaled up by the central and state governments and the city
administrations in India. These approaches should accommodate the special needs of the
vulnerable and marginalized groups, especially in urban areas.
2. Inclusive business models addressing health sector gaps scaled up by the private sector.
3. Greater partnership and integration between the public and private health sectors.
4. Innovative financing platforms and approaches leveraged for increased scaling up of
healthcare innovations, including community level innovations.
5. Models of expanded healthcare financial risk coverage (including outpatient care and
wellness) adopted and scaled by the public and private sector.
6. Promising climate resilient models and approaches scaled up in public and private health
facilities and supply chain.
7. Promising Indian integrated healthcare approaches, business models, financing, and private
sector innovations adopted by third country governments and private sector players.

To deliver the above mentioned deliverables and results, the activity will work across the following
cross cutting components:
(i) Community engagement with focus on vulnerable populations
(ii) Governance and accountability, especially at state, district and municipal level
(iii) Digital health
(iv) Private sector engagement - platform based engagements
(v) Innovative financing - for government, nonprofit, healthcare micro enterprises, and insurance
(vi) Acceleration and scale up - going beyond testing and incubation and supporting adoption,
absorption and scale up by government and private sector

6. Guiding Principles
This activity supports USAID partnership with India to achieve shared global priorities, including

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G20 objectives related to pandemic preparedness, medical countermeasures, digital public goods,
climate change mitigation and adaptation, universal health coverage, and innovative financing. This
activity will strengthen the health system to progress towards universal health coverage, addressing
impoverishment due to high out-of-pocket expenses on healthcare, while responding to emerging
threats including emerging infectious diseases. This activity will also support the health system and
community resilience to challenges related to climate change. In addition, the activity will support
collaboration and integration between both public and private sector health stakeholders. It will
mobilize new resources for public health priorities through innovative private sector engagements;
It will also strategically leverage BMGF, GFATM, World Bank, ADB and other donor resources
received by the Indian government for climate and health actions.

The activity will be guided by the following principles:

1. Localisation to ensure programmatic and financial sustainability: USAID envisions
expanding the share of its programs that are locally led, in which a diverse group of local
actors define priorities, design projects, drive implementation, measure and evaluate
results, and more fully own and sustain efforts to save lives, reduce poverty, strengthen
democratic governance, reduce corruption, address climate change, work to prevent
conflicts, respond to global pandemics, and emerge from humanitarian crises. Localization
principles must also inform our engagement beyond our projects: our convenings, the
expertise we seek, our policy reform dialogues, and all the ways we engage in
development.
2. Inclusive and participatory: USAID will center its actions in the context of the diverse
communities in which we work and will engage local, marginalized, and underrepresented
groups as agents of change, especially in urban areas.
3. Ecosystem approach: While the total central and state government annual health budget is
approximately $35 billion, the total healthcare segment in India is a $300 billion industry,
including private healthcare industry, medical technologies and equipment,
pharmaceuticals, health insurance, home based healthcare, etc. This overall health segment
of the Indian economy is growing at approximately 16% per year, making it the fastest
growing segment. It is also the largest employment generating segment in India. This
makes it imperative to approach health systems strengthening and scaling up innovative
approaches by developing synergies and linkages with platforms and institutions across the
healthcare ecosystem.
4. India for the World: Given India’s size, global reach (e.g. diaspora and trade relationships),
and vibrant innovation ecosystem, solutions to address global health system challenges can
be incubated in India and adapted for use across the world. The activity will adopt a
platforms-based approach to take Indian healthcare innovations to other partner countries
globally.

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 NOFO No: 72038624RFA00004: Health Systems
Strengthening (HSS) Activity

5. Progress Beyond Programs: Drive progress in ways that surpass the confines of the
USAID program budgets and related scope of implemented activities. This includes
embracing new, inclusive and ambitious partnerships.

The activity will address systemic barriers, such as governance, financing, provider and community
behaviors, etc. This activity will operate in close partnership with national and state governments,
networks of private health facilities, and private sector (like pharmaceutical industry and medical
device manufacturers). Digital health solutions will be compliant with the India Health Stack so as
to be interoperable across different levels of the health system.

7. Activity Parameters
a) Target Beneficiaries - The scaled health system approaches and models will target the
vulnerable populations in urban and rural areas, including the tribal communities, communities
residing in ecologically vulnerable areas like hills, forests, cyclone prone coastal areas, the slum
communities, LGBTQ populations, migrant and construction workers in selected states and
cities/towns as mentioned in section 4 above.

b) Gender and Social Inclusion - The activity will prioritize scaling up high-quality,
comprehensive, low cost, home-based or near-to-home healthcare and wellness models and
approaches, specifically targeted at women, and other underrepresented and underprivileged
communities. It will also work with city and state governments for strengthening public-private
partnerships and strategic purchasing models for ensuring higher quality and affordable healthcare,
especially for comprehensive primary healthcare, targeted at women, people with disability and
other marginalized populations. The activity will test models of financial risk protection especially
targeted at special health needs of women and other marginalized communities, both as publicly
subsidized models as well as low-cost business models. In addition, this activity will prioritize
providing support to public and private primary and secondary level facilities that are accessed
more by women, people with disabilities and other marginalized communities, for increased
adoption of climate resilient facility design and equipment and supplies.

c) Leverage - We expect at least 1:1 leverage in cash and preferably 1:2 to 1:5 leverage
(including cash and in-kind) from the implementing partners, with the additional funds leveraged
from government programs, quasi government entities, private sector and financial markets. This
implies USAID will fund up to 50% of the indicated TEC.

8. Monitoring, Evaluation and Learning

The goal of reduced OOPE and increased access and utilization of comprehensive primary
healthcare services will be obtained from large scale public databases like National Family Health
Survey (NFHS) and National Sample Surveys (NSS), the progress on results will be tracked
quarterly and annually from Project Management Information Systems (PMIS). Also, given the

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Strengthening (HSS) Activity

1+2+2 year break up of the activity period, progress feedback will be looped-in to plan for next
stages in the first and third year.

A Continuous Learning and Adaptation (CLA) approach will be taken to develop the detailed MEL
plan. Effort will be made to move away from the traditional 2Rs approach to MEL (measuring
Resource inputs and Results) and, instead, adopt a 5Rs approach to MEL (tracking Resources,
Rules, Roles, Relationships and Results), using mixed-methods approaches. This will be based on
the “5Rs Framework in the Program Cycle”14 published by USAID Learning Lab, recognizing the
pathway to results following complex adaptive systems in the context of health systems
strengthening. The activity will also undertake annual review of the “theory of change” to revalidate
the assumptions and results pathways throughout the activity duration.

A detailed MEL framework will be prepared after this Program Description is finalized in the co-
design phase.

[END OF SECTION A]

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14
Technical Note on “5Rs Framework in the Program Cycle”, version 2.1, by USAID Learning Labs; October 2016
accessed at [Link] on June 6,
2024

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SECTION B: FEDERAL AWARD INFORMATION

B.1 Estimate of Funds Available and Number of Awards Contemplated

USAID intends to award one (1) Fixed Amount Cooperative Agreement with option for renewal
period pursuant to this NOFO, however, USAID reserves the right to negotiate more than one award,
or no awards, pursuant to this NOFO.

Subject to funding availability, USAID intends to provide up to $20,000,000 in total USAID funding
over a five year period over two phases.

Base Period (Project Years 1 to 2): Initial award up to $6,000,000. Renewal Period (Project Years 3
to 5): Budgeted at $14,000,000. Final amount to be determined in the programmatic review and
may be lower or higher depending on the situation.

Actual funding amounts are subject to availability of funds. USAID reserves the right to fund any or
none of the applications submitted.

B.2 Expected Performance Indicators, Targets, Baseline Data, and Data Collection

USAID/India intends for the activity to be subject to rigorous performance monitoring to (a) ensure
that milestones are being met, and (b) inform activity management if, and when, course corrections
may be necessary. The recipient should also conduct several periodic reviews and analyses of the
performance to better understand certain aspects and implementation issues within the award’s
domain.

Performance monitoring parameters will be included by the Applicant while designing their technical
approach or milestones. USAID may conduct additional monitoring and performance assessment
through external contract(s). A detailed Activity monitoring plan will be developed soon after the
initiation of the project with detailed baseline information and will include appropriate targets and
indicators to measure the progress based on the expected objectives of the activity as detailed in the
Program Description or milestones.

USAID/India recognizes that development efforts yield positive change more quickly if they are
coordinated and collaborative, test promising new approaches in a continuous search for
improvement, and build on what works, while eliminating what does not. The recipient must therefore
implement a Collaborating, Learning and Adaptation (CLA) approach to continuously assess the
activity’s causal pathways, target outcomes, and adjust the interventions and approach as necessary
to yield the most effective course of action.

B.3 Start Date and Period of Performance for Federal Award

The anticipated total period of performance is up to five years. The estimated start date will be upon
the issuance of the awards by the Agreement Officer.

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Strengthening (HSS) Activity

B.4 Award Renewal

The HSS activity will be a milestone-based fixed amount cooperative agreement divided into two
performance periods, the Base Period (project years 2) and the Renewal Period (project years 3). The
initial duration of the award will be two years (Base Period), with an option to renew for another 3
years (Renewal Period). Renewal of the award is conditioned upon the availability of funds;
satisfactory progress toward meeting the award objectives; submission of required reports; and
compliance with the terms and conditions of the award, including the conditions for renewal.

a. Timing of Renewals

USAID will conduct the mid-term and final programmatic review of the Base period activities at 12
months and 20 months after the award respectively. Based on the successful achievement of the
following renewal conditions USAID will invite the applicant to submit the detailed application for
the Renewal period. Below are the Renewal period conditions:

Subject to availability of funds, USAID will invite the applicant to submit a detailed application to
continue implementation of the Renewal period activities.
● USAID will assess the applicant’s progress towards meeting the award objectives based on the
results of the final programmatic review of the Base period of implementation.
● USAID will also assess and take into consideration the timely submission of the required program
reports both technical and financial.
● USAID will also review the applicant’s compliance with the terms and conditions of the award
including the renewal conditions including the required risk-assessment requirements.
● As part of the re-application process, if required, USAID may revise the award and define further
activities within the general program description of the award.

Based on the successful achievement of the renewal conditions as stated above, the applicant must
reapply for the Renewal period activities at least three months prior to the completion of the Base
period of implementation.

If the Renewal period is executed, the start date of the renewal period will be concurrent with the
expiration date of the Base period to prevent a break in the activities or funding. In the event the
award is not renewed, USAID will inform the recipient in a timely manner and provide sufficient
time to complete the program activities prior to the end date of the initial award period.

b. Renewal Application Instructions

The Recipient’s reapplication will include:

● Proposed Milestones for the Renewal Period
● Detailed Budget to complete the proposed Milestones, along with a Budget Narrative
● Technical Approach for the Renewal Period
● Organizational and Staffing Plan for Renewal Period

In addition, the recipient will resubmit a new SF-424 and a new set of certifications, assurances,
representations, and other statements (see 303.3.8, Pre-Award Certifications, Assurances,

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Representations, and Other Statements of the Recipient and Pre-Award Terms), along with the
request for renewal. The AO may renew the award through a modification for the renewal period (yr.
3-5).

c. Criteria for Renewal

USAID will evaluate the Renewal re-application based on the following:

● Recipient’s satisfactory performance towards meeting the Base award objectives;

● Renewal award’s activity’s relevance to Agency objectives;
● The renewal will support either the same work, or work that is within the programmatic
activities of the Base award or is closely related to the Base award programmatic activities;
● The renewal supports the same long-term goal as the Base award, with new specific targets,
milestones, outputs, or indicators; and
● Recipient continues to meet the required risk-assessment requirements.

If the Renewal period is executed, the start date of the renewal period will be concurrent with the
expiration date of the Base award to prevent a break in the activities or funding. In the event the award
is not renewed, USAID will inform the recipient in a timely manner and provide sufficient time to
complete the program activities prior to the end date of the award Base Period.

NOTE: The renewal process will be initiated only with the implementing partner, who was
determined the most successful applicant and received the initial award.

B.5 Substantial Involvement

In accordance with ADS 303.3.11, USAID/India shall be substantially involved during the
implementation of this award, through the Agreement Officer's Representative (AOR)’s approval of
the following:

a. Approval of recipient’s Annual Implementation Plans including milestone plans. The

Annual Implementation Plan will act as a living document. It will provide specific planning for the
year. A quarterly review of the plan will take place with the AOR. The AOR will participate in the
quarterly review and any updates to the Annual Implementation Plan will be documented in email to
the AOR along with the submission of the updated plan. The Annual Implementation Plan will detail
specific tasks/activities per milestone, with an associated schedule for completion in accordance with
the milestone schedule.

b. Recipient to obtain AOR’s approval prior to hiring the key personnel on the following
Key Personnel Positions, to achieve award’s objectives:

1. Project Director
2. Monitoring, Evaluation & Learning (MEL) Lead
3. Health Systems Lead
4. Community Lead
5. Private Sector and Financing Lead

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c. Collaboration with USAID to facilitate coordination and communication with key

stakeholders:

Joint collaboration and engagement with national and global technical working groups and other key
stakeholders; periodic collaboration with USAID to ensure global and national best practices on HSS
monitoring are followed.

NOTE: This Substantial Involvement section is subject to change following the Co-Creation
Workshop and submission of the Final Application Phase.

B.6 Authorized Geographic Code

The authorized Geographic Code for the procurement of commodities and services under this
program is 937, which is defined as the United States, the recipient country, and developing countries
other than advanced developing countries, but excluding any country that is a prohibited source.
There are currently no prohibited source countries, but the list is updated regularly and can be found
here:
[Link]

B.7 Nature of the Relationship between USAID and the Recipient

The principal purpose of the relationship with the Recipient and under the subject program is to
transfer funds to accomplish a public purpose of the HSS activity which is authorized by Federal
Statute. The Recipient is 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 Successful Recipient assumes responsibility for administering Federal funds in a
manner consistent with underlying agreements, program objectives, and the terms and conditions of
the Federal award.

[END OF SECTION B]

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 NOFO No: 72038624RFA00004: Health Systems
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SECTION C: ELIGIBILITY INFORMATION

C.1 Eligible Applicants

Eligibility for this NOFO is open to all eligible and qualified U.S., local and international non-
governmental entities. An organization may submit only one (1) application under this notice of
funding opportunity. However, organizations participating as a member of a consortium may elect to
participate in another consortium for a different Organization/Firm in response to this NOFO.

For direct awards to proposed local consortium partners, USAID reserves the right to determine the
type of assistance instrument, for example, Cost reimbursement or Fixed Amount Award.

Profit is not allowable for recipients or subrecipients under this award. While for-profit organizations
may participate, pursuant to 2 CFR 700.13(a)(1), Prohibition against Profit, no profit/fee will be paid
to any entity/organization receiving or administering Federal financial assistance as a recipient or
subrecipient (consortium partner). Applicant/recipient is responsible for complying with all
applicable U.S. and Government of India laws and regulations.

USAID welcomes organizations that have not previously received financial assistance from USAID.
Faith-based organizations are eligible to apply for federal financial assistance on the same basis as
any other organization and are subject to the protections and requirements of Federal law.

C.2 Leverage

Leverage is defined as anything of value that is measured, financial contributions, third party
contributions, donated services or property, or intellectual property. USAID/India encourages the
applicant to leverage resources from either private or public resources. The applicant will work
towards leveraging resources- programmatic and financial, from both the private and public partners
to enable the activity to engage in interventions that are of shared interest and that are sustainable and
will enable the interventions to be continued after the Activity ends.
For more information on leverage, please visit
[Link]

C.3 Other

An organization may submit only one (1) concept paper under this notice of funding opportunity.
However, organizations participating as a member of a consortium may elect to participate in another
consortium under a different concept paper.

It shall be the responsibility of the applicant organization to be compliant with the local Government’s
Foreign Contribution Regulation Act (FCRA), if required, for receiving US Government funds
through a federal assistance program.

In support of the Agency’s interest in fostering a larger assistance base and expanding the number
and sustainability of development partners, USAID encourages applications from potential new and

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Strengthening (HSS) Activity

underutilized implementing partners who may not have previously received financial assistance from
USAID. Any resultant award to a new organization may require a pre-award review of the
organizations as part of a “risk assessment” of a potential recipient.

New partner is defined as an organization that has never received direct or indirect awards from
USAID. An underutilized partner is defined by the Agency as an organization that has received less
than $25 million in direct or indirect awards from USAID over the past five years. The five years is
relative to when the organization is applying to a USAID procurement/funding opportunity.

Non-U.S. Organization Pre-award Survey Guidelines and Support is available in the following link:
[Link]

END OF SECTION C

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SECTION D: APPLICATION AND SUBMISSION INFORMATION

D.1 Agency Point of Contact

Name: Cheryl Hodge-Snead

Title: Agreement/contracting Officer
Email: chodge-snead@[Link]

D.2 Questions and Answers

Questions regarding this NOFO should be submitted to indiarco@[Link], with a copy to

smadan@[Link] no later than the date and time indicated on the cover letter or as per any
amendment to this NOFO. Any information given to a prospective applicant concerning this NOFO
will be furnished promptly to all other prospective applicants as an amendment to this NOFO, if that
information is necessary in submitting applications or if the lack of it would be prejudicial to any
other prospective applicant.

Applicants must not submit questions to any other USAID staff. All the submission of questions
application files submitted must be compatible with Microsoft (MS) Office in a MS Windows
environment and/or Adobe Acrobat (.pdf). The subject of each e-mail must read as follows: NOFO
# 72038624RFA00004 - Health Systems Strengthening (HSS) Activity

D.3 General Content and Form of Application

Applicants are expected to review, understand, and comply with all aspects of this NOFO. Applicants
must ensure the necessary documents are complete and received by USAID on time. Failure to do
so will result in the submission being considered non-responsive and will not be reviewed. All
submissions received by the stated deadlines in the NOFO will be reviewed in accordance with the
review criteria contained in Section E of this NOFO.

Each applicant must furnish the information required by this NOFO for each phase and must be
submitted in accordance with the instructions provided under Section D. Any erasures or other
changes to the application must be initiated by the person signing the application. Applications signed
by an agent on behalf of the applicant must be accompanied by evidence of that agent’s authority
unless that evidence has been previously furnished to the issuing office.

Applicants may choose to submit a cover letter in addition to the cover pages, but it will serve only
as a transmittal letter to the Agreement Officer. The cover letter will not be reviewed as part of the
merit review criteria. USAID will not review any pages in excess of the page limits noted in the
subsequent sections. Please ensure that applications comply with the page limitations.

Submissions must be in electronic format. Applicants’ authorized representatives are to sign their
names (manually or digitally) on the cover pages of their submissions, as well as in required
certifications. For a submission to be considered timely, the electronic transmission must be
submitted by email to indiarco@[Link] with a copy to smadan@[Link] and received by

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Strengthening (HSS) Activity

USAID/India no later than the date and time indicated on the coversheet of the NOFO. USAID bears
no responsibility for data errors resulting from transmission or conversion processes associated with
electronic submissions.

Applicants not selected for the consecutive phase will be notified at the end of each phase. Depending
on the number of applicants, the AO may or may not respond to requests for additional information
from unsuccessful applicants.

D.4 Application Formats:

Each applicant must furnish the information required by this NOFO. This subsection addresses
content requirements applying to this NOFO. Please see subsections D.5 and D.6, below, for
information on the content specific to the application.

Concept papers must be submitted by email to indiarco@[Link], with a copy to

smadan@[Link] no later than the date and time indicated on the cover letter, as amended. Email
submissions must include the NOFO number and applicant’s name in the subject line heading.

After sending the concept paper electronically, applicants should immediately check their own email
to confirm that the attachments were indeed sent. If an applicant discovers an error in transmission,
please send the material again and note in the subject line of the email that it is a "corrected"
submission. Do not send the same email more than once unless there has been a change, and if so,
please note that it is a "corrected" email.

Applicants are reminded that email is NOT instantaneous, and in some cases delays of several hours
occur from transmission to receipt. Therefore, applicants are requested to send the application in
sufficient time ahead of the deadline. For this NOFO, the initial point of entry to the government
infrastructure is the USAID mail server.

There may be a problem with the receipt of *.zip files due to anti-virus software. Therefore, applicants
are discouraged from sending files in this format as USAID/India cannot guarantee their acceptance
by the internet server.

Application must comply with the following:

● USAID will not review any pages in excess of the page limits noted in the subsequent
sections. Please ensure that applications comply with the page limitations.
● Written in English.
● Use standard 8 ½” x 11”, single sided, single-spaced, 12-point Times New Roman font, 1”
margins, left justification and headers and/or footers on each page including consecutive
page numbers, date of submission, and applicant’s name.
● A 10-point font can be used for graphs and charts. Tables, however, must comply with the
12-point Times New Roman requirement.
● Submitted via Microsoft Word or PDF formats.
● Applicants must review, understand, and comply with all aspects of this NOFO. Failure to
do so may be considered as being non-responsive and may be evaluated accordingly.
Applicants should retain a copy of the application and all enclosures for their records.

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Strengthening (HSS) Activity

DO NOT SUBMIT: Promotional literature and materials regarding the Applicant or other unsolicited
material.

D.4.1. PHASE 1: Concept Paper Format

The concept paper is to be specific, complete, and presented concisely. The concept must demonstrate
the applicant’s capabilities and expertise with respect to achieving the goals of this program. The
concept is to consider the requirements of the program and merit review criteria found in this NOFO.

Applicants should also ensure that their concept paper contains the following aspects:

● List of Acronyms (does not count towards page limitation)

● Table of Contents (does not count towards page limitation)

No other documents/annexures are being requested currently; USAID will inform the applicants
about additional documentation required in subsequent phases, if needed.

A Concept Paper can be no more than a maximum of 8 pages (exclusive of annexures), where the
applicant provides an overview of its idea. Please see Concept Paper Instructions below. Applicants
must submit a Concept Paper by the deadline specified in this NOFO. USAID will review Concept
Papers against merit review criteria detailed in Section E of this NOFO.

Concept Paper must include a cover page containing the following information:

A. Concept Paper Cover Page (does not count towards page limitation):

The concept paper must include a cover page containing the following information:
● Proposed Activity Name/Title
● Period of Performance (i.e., start date and end date)
● Total Amount of Funding Requested from USAID
● Total amount leveraged, including from what source(s)
● Applicant Organization Name
● Applicant Contact Person (name, phone, e-mail)
● Full Address for Applicant Organization
● Type of Organization [please include certification of incorporation as Annex] (e.g., US. non-
US, multilateral, private, for-profit, nonprofit, etc) date of incorporation
● Notice of Funding Opportunity number
● (if Applicable) Name(s) of Partner(s) Organization(s)

Applicants may choose to submit a cover letter in addition to the cover pages, but it will serve only
as a transmittal letter to the Agreement Officer. The cover letter will not be reviewed as part of the
merit review criteria.

B. Include major sections and page numbering to easily cross-reference and identify the information
below.

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C. Concept Technical Approach (5 pages)

In this section, the Applicant must describe how they propose to achieve the objectives and targets
and provide its overall vision. The Technical Approach should be based on evidence and sound
theories of change that illustrate how the proposed activities will lead to the desired outputs,
outcomes, and results that meet the selection criteria. This should describe the technical approaches
as mentioned below under “strategies and approaches”. In addition, the concept papers should also
describe your organization’s approach for tackling the challenges and objectives described in Section
A of the NOFO.

At a minimum, this section must contain:

a. Summary Statement: A brief statement of the problem(s)/issue(s) being addressed, and

proposed strategies/activities.

b. Timeline: Proposed timeline for achieving results, i.e., project duration or time needed to
complete the proposed activities.

c. Describe the interventions the organization will take to meet the stated objectives in
Section A of the NOFO and describe the anticipated results and/or impact of the proposed
intervention.

d. Strategies and approaches: This must include strategies to scale innovative approaches in
reducing under-50 mortality by strengthening comprehensive primary healthcare with continuum of
care across secondary and tertiary level, while ensuring inclusiveness, especially of marginalized
groups like tribals, LGBTQ and urban poor and migrant communities. Further, it should also include
approaches to raise private (philanthropic and commercial capital) and government resources to
realize at least 1:1 match with USAID funding; include plan to ensure locally-led activity, involving
local organizations for implementation; strategies for partnering with existing USAID projects and
activities; and approaches for using existing government and private institutions and platforms at the
local, state, national and international levels for the scale up plan.

D. Organizational Structure and Management (1.5 page)

● Provide a description of the management approach for this activity that ensures a multidisciplinary
team, with the management support to project implementation staff ratio favoring implementation,
and shows the relationship within the team and between partner organizations (as applicable). As
applicable, articulate the role of each member organization of the consortium and their respective
contributions.
● Describe how your proposed concept will partner with and leverage experience(s) from local Indian
government and private organizations in the field of health systems, especially primary healthcare
with assured secondary and tertiary linkages, pandemic preparedness and global health security,
urban health, climate and environmental health, digital health, private sector engagement, and
innovative financing, including financial risk protection.
● Additionally, identify four to five positions/ key personnel that would be critical to accomplishing
the outcomes outlined in the Concept Technical Approach and describe the qualifications for each
position and why it is critical to successful implementation of the project.

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E. Institutional Capacity and History of Performance: (1.5 pages)

Describe the institutional capacity – technical, managerial, and financial – to carry out the proposed
intervention, and demonstrated ability to raise private (philanthropic and commercial) and
government resources. Describe your organization’s relevant previous experiences, from the past five
years, working on projects related to health systems, pandemic preparedness, urban health, climate
and environmental health, digital health, private sector engagement, and innovative financing,
including financial risk protection; highlighting the timeframe, scale, and geographic region for each
project. As applicable, provide information on institutional capacity and strengths of consortium
members.

In addition to the above stated main sections, the Applicant must also provide annexures (does not
count towards page limitation) including, but not limited to the following:

● Organizational Chart
● Recommended intervention locations along with a reasonable justification
● Evidence based scaling up plan around the activity including identification of relevant data pointers,
data collection, analysis, reporting and dissemination along with an approach towards acceleration
support for scale.

F. Name and Signature of authorized individual (does not count towards page limitation):
Any erasures or other changes to the concept paper must be initiated by the person signing. A concept
paper signed by an agent on behalf of the applicant must be accompanied by evidence of that agent’s
authority unless that evidence has been previously furnished to the issuing office.

D.5. REQUIREMENTS FOR A FULL APPLICATION (For Information Purpose Only)

NOTE: ONLY THOSE APPLICANT(S) WHO ARE SUCCESSFUL AT PHASE 3 WILL BE

REQUESTED TO SUBMIT A FULL APPLICATION. NO FULL APPLICATION IS
REQUIRED AT THIS TIME.

Please note additional requirements below that must be met prior to award and as part of the Full
Application evaluation stage:

(a) Business (cost) Application Format

NO Business (Cost) Application Is Required At Phase 1, 2 and 3. The following information is

provided for information purposes only for the applicant(s) that will be required to submit a full
application after successful co-creation at Phase 2.

(b) Certifications and Assurances

As part of Phase 4 (Full Application stage), the Application must complete the following documents,
upon request by the AO:

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 NOFO No: 72038624RFA00004: Health Systems
Strengthening (HSS) Activity

(1) “Certifications, Assurances, Representations, and Other Statements of the Recipient” ADS
303mav document found at
[Link]
(2) Assurances for Non-Construction Programs (SF-424B)
(3) Certificate of Compliance: Please submit a copy of your Certificate of Compliance if your
organization's systems have been certified by USAID/Washington's Office of Acquisition and
Assistance (M/OAA).

(c) Consortium arrangements

If the Applicant has established a consortium or another legal relationship among its partners, the
Cost/Business application must include a copy of the legal relationship between the parties. The
agreement should include a full discussion of the relationship between the Applicant and Sub-
Applicant(s) including identification of the Applicant with whom USAID will work with for purposes
of Agreement administration, identity of the Applicant which will have accounting responsibility,
how Agreement effort will be allocated and the express agreement of the principals thereto to be held
jointly and severally liable for the acts or omissions of the other.

(d) Unique Entity Identifier (UEI) and SAM Requirements

USAID may not award to an applicant unless the applicant has complied with all applicable unique
entity identifier (earlier known as DUNS number) and System for Award Management (SAM)
requirements. If requested to submit information as part of Phase 3, the applicant(s) (unless the
applicant is an individual or Federal awarding agency that is exempted from requirements under 2
CFR 25.110(b) or (c), or has an exception approved by the Federal awarding agency under 2 CFR
25.110(d)) is required to:

1. Provide a valid UEI number for the applicant and all proposed sub-recipients (if any).
2. Be registered in SAM prior to the issuance of an award. ([Link]
3. 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.

The registration process may take many weeks to complete. Therefore, applicants are encouraged to
begin the process early. If an applicant has not fully complied with the requirements above by the
time USAID is ready to make an award, USAID may determine that the applicant is not qualified to
receive an award and use that determination as a basis for making an award to another applicant.

UEI number and SAM registration: [Link]

Applicants can find additional resources for registering in SAM, including a Quick Start Guide and
a video on how to obtain an NCAGE code, on [Link] navigate to Help, then
to International Registrants.

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Strengthening (HSS) Activity

(e) Negotiation

Upon consideration of award or during the negotiations leading to an award, Applicants may be
required to submit additional documentation deemed necessary for the Agreement Officer to make
an affirmative determination of responsibility. Applicants should not submit the information below
with their applications! The information in this section is provided so that Applicant may become
familiar with additional documentation that may be requested by the Agreement Officer:

● Bylaws, constitution, and articles of incorporation, if applicable.

● Whether the organizational travel, procurement, financial management, accounting manual and
personnel policies and procedures, especially regarding salary, promotion, leave, differentials, etc.,
submitted under this section have been reviewed and approved by any agency of the Federal
Government, and if so, provide the name, address, and phone

(e) Branding Strategy & Marking Plan

The apparently successful applicant will be asked to provide a Branding Strategy and Marking Plan
to be evaluated and approved by the Agreement Officer and incorporated into any resulting award.

Branding Strategy – Assistance (June 2012)

a. Applicants recommended for an assistance award must submit and negotiate a "Branding
Strategy," describing how the program, project, or activity is named and positioned, and how it is
promoted and communicated to beneficiaries and host country citizens.

b. The request for a Branding Strategy, by the Agreement Officer from the applicant, confers
no rights to the applicant and constitutes no USAID commitment to an award.
c. Failure to submit and negotiate a Branding Strategy within the time frame specified by the
Agreement Officer will make the applicant ineligible for an award.

d. The applicant must include all estimated costs associated with branding and marking USAID
programs, such as plaques, stickers, banners, press events, materials, and so forth, in the budget
portion of the application. These costs are subject to the revision and negotiation with the Agreement
Officer and will be incorporated into the Total Estimated Amount of the grant, cooperative agreement,
or other assistance instrument.

e. The Branding Strategy must include, at a minimum, all of the following:

(1) All estimated costs associated with branding and marking USAID programs, such as plaques,
stickers, banners, press events, materials, and so forth.

(2) The intended name of the program, project, or activity.

(i) USAID requires the applicant to use the “USAID Identity,” comprised of the USAID logo
and brandmark, with the tagline “from the American people” as found on the USAID Web site at
[Link] unless Section VI of the RFA or APS states that the USAID

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Administrator has approved the use of an additional or substitute logo, seal, or tagline.
(ii) USAID prefers local language translations of the phrase “made possible by (or with) the
generous support of the American People” next to the USAID Identity when acknowledging
contributions.
(iii) It is acceptable to cobrand the title with the USAID Identity and the applicant's identity.
(iv) If branding in the above manner is inappropriate or not possible, the applicant must explain
how USAID's involvement will be showcased during publicity for the program or project.
(v) USAID prefers to fund projects that do not have a separate logo or identity that competes
with the USAID Identity. If there is a plan to develop a separate logo to consistently identify this
program, the applicant must attach a copy of the proposed logos. Section VI of the RFA or APS will
state if an Administrator approved the use of an additional or substitute logo, seal, or tagline.
(3) The intended primary and secondary audiences for this project or program, including direct
beneficiaries and any special target segments.
(4) Planned communication or program materials used to explain or market the program to
beneficiaries.

(i) Describe the main program message.

(ii) Provide plans for training materials, posters, pamphlets, public service announcements,
billboards, Web sites, and so forth, as appropriate.

(iii) Provide any plans to announce and promote publicly this program or project to host country
citizens, such as media releases, press conferences, public events, and so forth. Applicant must
incorporate the USAID Identity and the message, “USAID is from the American People.”

(iv) Provide any additional ideas to increase awareness that the American people support this
project or program.

(5) Information on any direct involvement from the host-country government or ministry,
including any planned acknowledgement of the host-country government.

(6) Any other groups whose logo or identity the applicant will use on program materials and
related materials. Indicate if they are a donor or why they will be visibly acknowledged, and if they
will receive the same prominence as USAID.

f. The Agreement Officer will review the Branding Strategy to ensure the above information is
adequately included and consistent with the stated objectives of the award, the applicant's cost data
submissions, and the performance plan.

g. If the applicant receives an assistance award, the Branding Strategy will be included in and
made part of the resulting grant or cooperative agreement.

Marking Plan – Assistance (June 2012)

a. Applicants recommended for an assistance award must submit and negotiate a “Marking
Plan,” detailing the public communications, commodities, and program materials, and other items
that will visibly bear the “USAID Identity,” which comprises of the USAID logo and brandmark,

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with the tagline “from the American people.” The USAID Identity is the official marking for the
Agency, and is found on the USAID Web site at [Link] Section VI of the
RFA or APS will state if an Administrator approved the use of an additional or substitute logo, seal,
or tagline.

b. The request for a Marking Plan, by the Agreement Officer from the applicant, confers no
rights to the applicant and constitutes no USAID commitment to an award.

c. Failure to submit and negotiate a Marking Plan within the time frame specified by the
Agreement Officer will make the applicant ineligible for an award.

d. The applicant must include all estimated costs associated with branding and marking USAID
programs, such as plaques, stickers, banners, press events, materials, and so forth, in the budget
portion of the application. These costs are subject to the revision and negotiation with the Agreement
Officer and will be incorporated into the Total Estimated Amount of the grant, cooperative agreement,
or other assistance instrument.

e. The Marking Plan must include all of the following:

(1) A description of the public communications, commodities, and program materials that the
applicant plans to produce, and which will bear the USAID Identity as part of the award, including:

(i) Program, project, or activity sites funded by USAID, including visible infrastructure projects
or other sites physical in nature;

(ii) Technical assistance, studies, reports, papers, publications, audio- visual productions, public
service announcements, Web sites/Internet activities, promotional, informational, media, or
communications products funded by USAID;

(iii) Commodities, equipment, supplies, and other materials funded by USAID, including
commodities or equipment provided under humanitarian assistance or disaster relief programs; and

(iv) It is acceptable to cobrand the title with the USAID Identity and the applicant's identity.

(v) Events financed by USAID, such as training courses, conferences, seminars, exhibitions,
fairs, workshops, press conferences and other public activities. If the USAID Identity cannot be
displayed, the recipient is encouraged to otherwise acknowledge USAID and the support of the
American people.

(2) A table on the program deliverables with the following details:

(i) The program deliverables that the applicant plans to mark with the USAID Identity;

(ii) The type of marking and what materials the applicant will use to mark the program
deliverables;

(iii) When in the performance period the applicant will mark the program deliverables, and where
the applicant will place the marking;

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(iv) What program deliverables the applicant does not plan to mark with the USAID Identity, and

(v) The rationale for not marking program deliverables.

(3) Any requests for an exemption from USAID marking requirements, and an explanation of
why the exemption would apply. The applicant may request an exemption if USAID marking
requirements would:

(i) Compromise the intrinsic independence or neutrality of a program or materials where

independence or neutrality is an inherent aspect of the program and materials. The applicant must
identify the USAID Development Objective, Interim Result, or program goal furthered by an
appearance of neutrality, or state why an aspect of the award is presumptively neutral. Identify by
category or deliverable item, examples of material for which an exemption is sought.

(ii) Diminish the credibility of audits, reports, analyses, studies, or policy recommendations
whose data or findings must be seen as independent. The applicant must explain why each particular
deliverable must be seen as credible.

(iii) Undercut host-country government “ownership” of constitutions, laws, regulations, policies,

studies, assessments, reports, publications, surveys or audits, public service announcements, or other
communications. The applicant must explain why each particular item or product is better positioned
as host-country government item or product.

(iv) Impair the functionality of an item. The applicant must explain how marking the item or
commodity would impair its functionality.

(v) Incur substantial costs or be impractical. The applicant must explain why marking would not
be cost beneficial or practical.

(vi) Offend local cultural or social norms or be considered inappropriate. The applicant must
identify the relevant norm and explain why marking would violate that norm or otherwise be
inappropriate.

(vii) Conflict with international law. The applicant must identify the applicable international law
violated by the marking.

f. The Agreement Officer will consider the Marking Plan's adequacy and reasonableness and
will approve or disapprove any exemption requests. The Marking Plan will be reviewed to ensure the
above information is adequately included and consistent with the stated objectives of the award, the
applicant's cost data submissions, and the performance plan.

g. If the applicant receives an assistance award, the Marking Plan, including any approved
exemptions, will be included in and made part of the resulting grant or cooperative agreement, and
will apply for the term of the award unless provided otherwise.

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(f) Funding Restrictions

Profit is not allowable for recipients or subrecipient(s) under this award. See 2 CFR 200.331 for
assistance in determining whether a sub-tier entity is a subrecipient or contractor.

Construction will not be authorized under this award.

USAID will not allow the reimbursement of pre-award costs under this award without the explicit
written approval of the Agreement Officer.

Except as may be specifically approved in advance by the AO, all commodities and services that will
be reimbursed by USAID under this award must be from the authorized geographic code specified in
Section B.6 of this NOFO and must meet the source and nationality requirements set forth in 22 CFR
228.

(g) Conscience Clause Implementation (Assistance) – Solicitation Provision (February

2012)
(a) An organization, including a faith-based organization, that is otherwise eligible to receive
funds under this agreement for HIV/AIDS prevention, treatment, or care—

1) Shall not be required, as a condition of receiving such assistance—

(i) to endorse or utilize a multisectoral or comprehensive approach to combating HIV/AIDS; or
(ii) to endorse, utilize, make a referral to become integrated with, or otherwise participate in any
program or activity to which the organization has a religious or moral objection; and
2) Shall not be discriminated against in the solicitation or issuance of grants, contracts, or
cooperative agreements for refusing to meet any requirement described in paragraph (a)(1) above.

(b) An applicant who believes that this solicitation contains provisions or requirements that
would require it to endorse or use an approach or participate in an activity to which it has a religious
or moral objection must so notify the cognizant Agreement Officer in accordance with the Mandatory
Standard Provision titled “Notices” as soon as possible, and in any event not later than 15 calendar
days before the deadline for submission of applications under this solicitation. The applicant must
advise which activity(ies) it could not implement and the nature of the religious or moral objection.

(c) In responding to the solicitation, an applicant with a religious or moral objection may
compete for any funding opportunity as a prime partner, or as a leader or member of a consortium
that comes together to compete for an award. Alternatively, such an applicant may limit its application
to those activities it can undertake and must indicate in its submission the activity(ies) it has excluded
based on religious or moral objection. The offeror’s proposal will be evaluated based on the activities
for which a proposal is submitted and will not be evaluated favorably or unfavorably due to the
absence of a proposal addressing the activity(ies) to which it objected and which it thus omitted. In
addition to the notification in paragraph (b) above, the applicant must meet the submission date
provided for in the solicitation.

(h) Conflict of Interest Pre-Award Term (August 2018)

(a) Personal Conflict of Interest

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1) An actual or appearance of a conflict of interest exists when an applicant organization or an

employee of the organization has a relationship with an Agency official involved in the competitive
award decision-making process that could affect that Agency official’s impartiality. The term
“conflict of interest” includes situations in which financial or other personal considerations may
compromise, or have the appearance of compromising, the obligations and duties of a USAID
employee or recipient employee.
2) The applicant must provide conflict of interest disclosures when it submits an SF-424. Should
the applicant discover a previously undisclosed conflict of interest after submitting the application,
the applicant must disclose the conflict of interest to the AO no later than ten (10) calendar days
following discovery.

(b) Organizational Conflict of Interest

The applicant must notify USAID of any actual or potential conflict of interest that they are aware of
that may provide the applicant with an unfair competitive advantage in competing for this financial
assistance award. Examples of an unfair competitive advantage include but are not limited to
situations in which an applicant or the applicant’s employee gained access to non-public information
regarding a federal assistance funding opportunity, or an applicant or applicant’s employee was
substantially involved in the preparation of a federal assistance funding opportunity.

USAID will promptly take appropriate action upon receiving any such notification from the applicant.

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SECTION E: APPLICATION REVIEW INFORMATION

E.1 Criteria

All applications will be reviewed in accordance with the review criteria set forth below. The merit
review criteria prescribed here are tailored to the requirements of this particular NOFO.
Applicants should note that these criteria serve to: (a) identify the significant matters which the
applicants should address in their applications, and (b) set the standard against which all
applications will be evaluated.

Merit Review Factors will be evaluated relative to each other, as described here and prescribed by
the Technical Application Format.

E.2 Review and Selection Process

Phase 1 - Concept Paper

Concept Paper: The concept paper will be reviewed by a Merit Review Committee according to the
criteria described below. The purpose of this review is to shortlist those concepts that address result
areas mentioned in the draft program description, as per Section A, and fulfills the selection criteria
mentioned in Section E.2.1 below. A concept paper is determined to be acceptable if it proposes a
sound approach and USAID has Strong Confidence that the applicant understands the requirement
and will be successful in performing with no government intervention based on the criteria below,
which are listed in descending order of importance.

The Agreement Officer makes the final determination and is the only individual who may legally
commit the U.S. Government to the expenditure of public funds. No costs chargeable to the proposed
Agreement may be incurred before receipt of either an Agreement signed by the Agreement Officer
or a specific, written authorization from the Agreement Officer.

Phase 2 - Oral Presentations

Successful applicants whose application was conditionally accepted (based on the Merit Review
Criteria) will be invited to present their concept. The purpose of the presentation is to better
understand the concept and its approach to the solution, as well as provide USAID an opportunity to
pose clarifying questions. After the presentations, USAID will use the Merit Review Criteria to assign
a final rating to applicants. The outcomes of the presentation will be used to determine which concept
paper moves forward to the Co-Creation stage.

NOTE: USAID reserves the right to consider co-creating with all applicant(s) whose concept papers
were conditionally accepted up until the award is made. For example, should a viable solution not
materialize with the applicant whose concept paper was accepted, USAlD will commence co-creation
with the next viable applicant. USAID will provide a written summary feedback to applicant(s) who
will remain in the conditionally acceptable category to those applicant/s who were invited for an oral
presentation. Those applicant(s) whose concept paper was not accepted will have the opportunity to
request additional information. The process ends for applicants who were notified that their

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concept paper was not accepted. No further consideration will be given to those applicant(s).

NOTE: After concept paper/s have been accepted, detailed activity design discussions between
USAID and the applicant will begin and continue throughout the remainder of the process.

NOTE: USAID reserves the right to accept a concept paper that fully meets the requirements of the
NOFO, not hold oral presentations, and proceed directly to Phase 3 - Co-creation.

USAID will not be responsible for costs associated with presentation.

Phase 3 - Co-Creation Workshop

Only the most likely successful applicant(s) from the Phase 2 Merit Review will be invited to join the
co-creation [Link] applicant will be sent an invitation letter requesting a draft Program
Description and notifying the applicant of the date, time, and venue for the workshop. Specific details
will be included in the invitational letter. Participants will include the applicant, USAID, and
potentially other stakeholders such as the representatives from the government, private sector and the
marginalized communities. The applicant is required to include their personnel who will be actually
implementing the proposed activity.

No funding will be made available prior to the award of the Cooperative Agreement. Applicants,
including the organization selected to collaboratively develop the Program Description, are
responsible for all costs related to the oral presentation and the co-creation workshop. Once the award
is signed, the implementing partner may start incurring costs. Applicants not selected for the
consecutive phase will be notified at the end of each phase. Unsuccessful applicants may request
additional information following such notification.

USAID reserves the right to make no award under this NOFO at any stage of the process.

Phase 4: Request for final documents

At the end of the Co-Creation, Applicant(s) will be requested to submit final documents that
incorporate the feedback from USAID and the representatives from the government, private sector
and the marginalized communities during the co-creation workshop. Detailed requirements will be
included in the letter requesting final documents.

E.2.1 MERIT REVIEW

Phase 1 – Concept Paper

USAID will conduct a merit review of all concept papers received that comply with the instructions
in this NOFO. Applications will be reviewed and evaluated in accordance with the following criteria,
and the technical approach will be weighted more heavily, while the other factors will be weighted
equally.

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1) Technical Approach

a) Strategies to scale innovative approaches in reducing under-50 mortality by strengthening

comprehensive primary healthcare with continuum of care across secondary and tertiary level, while
ensuring inclusiveness, especially of marginalized groups like tribals, LGBTQ and urban poor and
migrant communities.
b) Approaches to raise private (philanthropic and commercial capital) and government
resources to realize at least 1:1 match with USAID funding.

2) Management and Institutional Capabilities

a) Plan to ensure locally-led activity, including plans to involve local organizations for
implementation.
b) Strategies for partnering with existing USAID projects and activities.
c) Approaches for using existing government and private institutions and platforms at the local,
state, national and international levels for the scale up plan.

3) Staffing Approach and Key Personnel

a) Multidisciplinary project team, with the management support to project implementation staff
ratio favoring implementation.
b) Demonstrated plan to onboard short-term technical assistance (STTA) for specialized
domain expertise.

USAID reserves the right to pose clarifying questions and conduct discussions with any applicant but
may not opt to do so if it believes it has sufficient information in the concept paper itself. Posing
clarifying questions and conducting discussions with one applicant does not obligate USAID to do
so with all applicants.

USAID anticipates two (2) possible results from the Concept Paper merit review process:

• CONDITIONALLY ACCEPTABLE - Concept paper is evaluated and based on the merit review
criteria the applicant is found to propose a good approach and USAID has Good Confidence that the
applicant understands the requirement, and will be successful in performing with little or no
government intervention. Applicant(s) whose concept paper is conditionally accepted are required to
attend an oral presentation to present their concept paper to receive further consideration.
• UNACCEPTABLE: Concept Paper is UNACCEPTABLE when evaluated against the merit
review criteria and is found to propose an unsound approach and USAID has Low Confidence that
the applicant understands the requirements. The applicant(s) will be unsuccessful in implementing
the program. If UNACCEPTABLE, USAID declines the concept paper. Due to the number of
concept papers received, USAID is not able to provide details on why the concept paper was not
selected.

After the oral presentation, USAID will determine whether or not the presented concepts address the
strategic objectives outlined in Section A of the NOFO. Only concepts that are acceptable will move
forward to the Co-Creation Workshop.

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• ACCEPTABLE - Concept paper is ACCEPTABLE when the applicant proposes a sound

approach and USAID has Strong Confidence that the applicant understands the requirements and
will be successful in performing with no government intervention. Applicants can only be rated as
ACCEPTABLE after the applicant(s) has orally presented a concept.

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SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION

1. Federal Award Notices

Notice of award signed by the Agreement Officer is the authorized document, which will be
transmitted to the successful Applicant following the selection. This will be sent to the authorized
agent of the successful Applicant electronically. The notice may be determined by the Agreement
Officer, identify clarifying questions and request for a revised application by a specified date prior to
finalization of the Cooperative Agreement. USAID reserves the right to award without requesting
clarification or additional detail on the application. Once all outstanding issues have been resolved,
the Agreement Officer will send the draft Cooperative Agreement to the Apparent recipient for
review, comments and or acceptance to be followed by full execution of the Cooperative Agreement.

Award of the agreement contemplated under this NOFO cannot be made until funds are 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 of the award. The Agreement Officer is the only individual who may
legally commit the Government to the expenditure of public funds.

Applicants are advised that costs incurred prior to receipt of either a fully executed Agreement (in
electronic or print form) or a specific, written authorization from the Agreement Officer are not
allowable and therefore are ineligible for reimbursement under the Agreement.

The Agreement Officer will also provide written notification electronically to the unsuccessful
Applicants’ Points of Contact. Requests for additional information from unsuccessful Applicants will
not be considered.

2. Administrative & National Policy Requirements

The resulting award from this NOFO will be administered in accordance with the following
policies and regulations.

For US organizations: ADS 303, 2 CFR 700, 2 CFR 200, 2024 Interim Standard Provisions for U.S.
Non Governmental Organizations;

For Non US organizations: ADS 303, 2024 Interim Standard Provisions for Non-U.S.
Nongovernmental Organizations and

Standard Provisions for Fixed Amount Awards to Nongovernmental Organizations

USAID/India Office of Acquisition and Assistance will administer this award. The Agreement
Officer will designate an Agreement Officer’s Representative (AOR) to review, concur and/or
approve on items outlined in the Substantial Involvement (Section B.5 of this NOFO).

3. Reporting Requirements

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The Recipient will adhere to all reporting requirements listed below; further, US Non governmental
organizations need to be in compliance with 2 CFR 200 and 2 CFR 700 (specifically 2 CFR
200.327-329).

The Recipient in conjunction with its consortium partners, will submit all reports by the due date for
approval from the Agreement Officer’s Representative (AOR). The Recipient will consult with the
AOR on the format and content prior to submission. In addition to the reports below, the AOR may
request additional information to contribute to the internal USAID project reviews.

F.3.1. Performance Reporting

Reports and Deliverables Due Dates

Activity Start-up Plan Within 30 calendar days after the award. The plan
should outline the Recipients plan for staffing, start-
up workshop and work plan and MEL plan
preparation.

Start-up workshop Within 75 calendar days after award to inform activity

theory of change, work plan and MEL plan

Annual Work Plan A draft first year work plan - 60 calendar days after
award (note: first year work plan should go from
activit start date through the end oaf the next
fiscal year so ma be longer or shorter than 12 months
depending on the date of the award.)

Subsequent annual work plans – October 1st of each

calendar year

Activity Monitoring, Evaluation and 30 calendar days after finalization of the first year
Learning (MEL) Plan work plan

Quarterly Progress Report 30 calendar days after the end of the quarter

Gender and Social Inclusion Plan 60 calendar days from the date of the award

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Mid-term Programmatic Review 15 calendar months from the date of the award to
assess the performance of implementation during
Phase 1.

Final Programmatic Review 30 calendar months from the date of the award to
conduct final assessment of the performance of Phase
1 implementation.

Annual Performance Report October 15th of each year

Final Report 30 calendar days prior to the end of the award

● Start-up Workshop - Within seventy-five days post-award the Recipient will hold a workshop
that includes USAID staff and relevant partners to guide development of the first year work plan,
activity theory of change and anticipated outcomes, and Monitoring and Evaluation (MEL) plan. The
workshop will also serve to define requirements and format for deliverables and reporting. The
objective of the workshop is to provide a dedicated forum for the activity consortium, USAID staff
and other relevant partners to collaborate to refine the submitted technical approach, theory of change
and anticipated outcomes, and MEL Plan. The cost of this 3–5-day workshop should be included in
the applicant's cost proposal. Note, at the discretion of the AOR, this workshop may include or be
done collectively with other mission implementing partners working on Health Systems
Strengthening .

● Annual Work Plan - The annual work plan details how the Recipient will use the work plan year
effectively to achieve the activity’s objective. The work plan serves as a guide to program
implementation and, once approved, represents an agreement as to the objectives and timing of
specific tasks and interventions. The work plan is intended to be an annual roadmap for USAID and
the Recipient. It should be closely aligned to the theory of change agreed upon during the start-up
workshop, and clearly explain how the actions and outputs will lead to the expected outcomes
identified in the theory of change. More details on the format of the implementation plan will be
provided after the award.

● Activity Monitoring, Evaluation and Learning (MEL) Plan - The Applicant must prepare a
clear MEL Plan for this activity that facilitates adaptive learning and management. The MEL plan
must provide an overview of the project’s objectives, theory of change and strategic approaches;
indicate the custom and standard indicators that will be used to monitor progress towards achieving
the stated objectives; and define the processes to monitor, analyze and evaluate progress. The plan
should outline opportunities for learning and adaptive management throughout all stages of the
project and include in its learning agenda evaluations or studies to assess and inform the roll out of
interventions. More details on the format of the MEL plan will be provided after the award.

● Quarterly Performance Reports - The Recipient will submit brief quarterly performance reports
to reflect progress, the activities of the preceding three months and lessons learned. The report must
describe the tasks completed in the last three months relative to what was anticipated in the approved

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work plan and will assess the overall activity impact to date relative to the performance indicator
targets and results defined in the activity theory of change. More details on the format of the quarterly
performance reports will be provided after the award.

● Gender Consideration: To the greatest extent possible, the Recipient should seek to include both
men and women in all aspects of this program including participation and leadership in e.g.,
meetings, training, etc. The Recipient must collect, analyze and submit to USAID sex-disaggregated
data and proposed actions that will address any identified gender related issues.

In order to ensure that USAID assistance makes the maximum optimal contribution to gender
equality, performance management systems and evaluations must include gender-sensitive indicators
and sex-disaggregated data when the technical analyses supporting the Agreement demonstrates that:

● The different roles and status of women and men affect the activities to be undertaken, and
● The anticipated results of the work would affect women and men differently.

● Programmatic Review: The programmatic review is a collaborative and course-corrective

measurement of the programmatic opportunities, challenges and successes of the activity during the
implementation cycle to determine whether continued investment in the activity will achieve defined
development results and goals. There is no pre-determined format for the programmatic and financial
performance which may either take the form of a reporting by partner or a defined assessment based
on primary data collection and stakeholder consultation. USAID will conduct a mid-term and final
programmatic review at the specific intervals of time during the Phase 1 implementation. Following
the conclusion of the programmatic review, USAID will formally inform of a positive/negative
determination to renew and continue support for the implementation of the award as well as of any
required pivots or adjustments to the activity to best achieve development objectives.

● Annual Performance Report - Annual performance reports will summarize actions, progress and
results during the year in relation to the approved work plan and the activity theory of change it
supports. The report should include lessons learned, proposed adaptive management shifts, and
proposed updates to the theory of change. The annual performance report will be used by USAID to
assess the status of activity implementation. Each annual performance report will include an
assessment as to whether the activity's strategic approaches and actions are leading to the activity
purpose. The annual performance report will cover all of the items included in the bi- annual
performance report, with a focus on the Activity results over the entire year. More details on the
format of the annual performance report will be provided after the award.

● Close-out Plan - No later than six (6) months prior to the completion date of the agreement, the
Recipient will submit a close-out plan for the Agreement Officer (AO) approval. The close out plan
shall include:

● Draft property disposition plan

● Plan for the phase-out of in-country operations
● Delivery schedule for all reports or other deliverables required under the agreement
● Timetable for completing all required actions in the close-out plan, including submission
date of the final property disposition plan to the AO.

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● Final Report - The Final Report must discuss all strategic approaches and results from the
start of the award through its completion. More details on the format of the final report will be
provided after the award.

F.3.2 Financial Reporting:

(1) Quarterly Financial Report

The Recipient must submit the Federal Financial Form (SF-425) quarterly, no later than 30 days after
the end of the quarter, via electronic format to the U.S. Department of Health and Human Services
([Link] The Recipient must submit a copy of SF‐425 at the same time to the
Agreement Officer Representative (AOR) and the Controller.

Electronic copies of SF-425 and instructions for using it can be found at:

[Link]

[Link]

[Link]

(2) Final Financial Report

Within 90 days following the estimated completion date of this award, the Recipient must submit
to the: (a) USAID/Washington, M/CFO/CMP-LOC Unit; (b) Agreement Officer (manila-roaa
admin@[Link]); (c) Controller (aidmnlrfsc@[Link]); and (c) Agreement Officer
Representative (AOR), the final Federal Financial Form (SF-425).

(3) Foreign Tax Reports

Reporting of foreign taxes under this agreement shall follow the standard provision entitled
“Reporting Host Government Taxes (December 2014)” of this award document.

Host government taxes are not allowable where the Agreement Officer provides the necessary means
to the recipient to obtain an exemption or refund of such taxes, and the recipient fails to take
reasonable steps to obtain such exemption or refund. Otherwise, taxes are allowable in accordance
with the Standard Provision, “Applicability of 2 CFR 200 and 2 CFR 700 (December 2014),” and
must be reported as required in this provision.

The Recipient must include this reporting requirement in all applicable sub-agreements, including
subawards and contracts.

F.4 Program Income

If the successful applicant is a non-profit organization, any program income generated under the
award will be added to USAID funding (and any cost-sharing that may be provided, if applicable),

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and used for program purposes. However, pursuant to 2 CFR 200.307 Program Income, if the
successful Applicant is a for-profit or commercial organization, any program
income generated under the award will be deducted from the U.S. Government share of this award
to determine the amount of USAID funding.

Program income will be subject to 2 CFR 200.307 for U.S. NGOs or the standard provision entitled
Program Income for non-U.S. NGOs. If the successful Applicant is/are a PIO, any program income
generated under the award will be added to USAID funding (and any non- USAID funding that may
be provided) and used for program purposes.

F.5 Environmental Compliance

1a). 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 201.5.10g and 204 ([Link]
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. Offeror environmental compliance obligations under these regulations and
procedures are specified in the following paragraphs of this Notice for Funding Opportunity (NOFO).

1b). In addition, the recipient must comply with host country environmental regulations unless
otherwise directed in writing by USAID. In case of conflict between host country and USAID
regulations, the latter shall govern.

1c) No activity funded under this NOFO will be implemented unless an environmental threshold
determination, as defined by 22 CFR 216, has been reached for that activity, as documented in a
Request for Categorical Exclusion (RCE), Initial Environmental Examination (IEE), or
Environmental Assessment (EA) duly signed by the Bureau Environmental Officer (BEO).
(Hereinafter, such documents are described as “approved Regulation 216 environmental
documentation.”)

2) An Initial Environmental Examination (IEE) has to be undertaken for this activity funding for
NOFO. The offeror shall be responsible for implementing all IEE conditions pertaining to activities
to be funded under this solicitation.

3a) As part of its initial Work Plan, and all Annual Work Plans thereafter, the recipient, in
collaboration with the USAID Assistance Office Representation (AOR) and Mission Environmental
Officer or Bureau Environmental Officer, as appropriate, shall review all ongoing and planned
activities under this NOFO to determine if they are within the scope of the approved Regulation 216
environmental documentation.

3b) If the recipient 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.

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3c) 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 USAID.

4a) If a provision for sub-grants is included under this award; the recipient will be required to use an
Environmental Review Form (ERF) or Environmental Review (ER) checklist using impact
assessment tools to screen grant proposals to ensure the funded proposals will result in no adverse
environmental impact, to develop mitigation measures, as necessary, and to specify monitoring and
reporting. Use of the ERF or ER checklist is called for when the nature of the grant proposals to be
funded is not well enough known to make an informed decision about their potential environmental
impacts, yet due to the type and extent of activities to be funded, any adverse impacts are expected
to be easily mitigated. Implementation of sub-grant activities cannot go forward until the ERF or ER
checklist is completed and approved by USAID.
Recipient is responsible for ensuring that mitigation measures specified by the ERF or ER a
checklist process is implemented.

5a) USAID anticipates that environmental compliance and achieving optimal development
outcomes for the proposed activities will require environmental management expertise.
Respondents to the NOFO should therefore include as part of their application their approach to
achieving environmental compliance and management, to include:

5b) The respondent’s approach to developing and implementing an environmental review process
for a grant fund and an EMMP.

5c) The respondent’s approach to providing necessary environmental management expertise,

including examples of past experience of environmental management of similar activities.

5d) The respondent’s illustrative budget for implementing the environmental compliance activities.
For the purposes of this solicitation, offerors should reflect illustrative costs for environmental
compliance implementation and monitoring in their cost proposal.

F.6 Branding & Marking

It is a federal statutory and regulatory requirement that all USAID programs, projects, activities,
public communications, and commodities that USAID partially or fully funded under a USAID grant
or cooperative agreement or other assistance award or sub-award, must be marked appropriately
overseas with the USAID identity. See Section 641, Foreign Assistance Act of 1961, as amended
and 2 CFR 700.16.

Under the regulation, USAID requires the submission of a Branding Strategy and a Marking Plan by
the Apparently Successful Applicant, as defined in the regulation. 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:

[Link]

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The Branding and Marking Plan may include a request for a waiver or exceptions to marking
requirements established in 2 CFR 700.16. The Agreement Officer is responsible for evaluating and
approving the Branding Strategy and Marking Plan (including any request for exceptions and waiver)
of the ASA, consistent with the provisions” Branding Strategy”, “Marking Plan”, and “Marking of
USAID-funded Assistance Awards” contained in AAPD 05-11 and in 2 CFR
700.16. Please note that in contrast to “exception” to marking requirements, waivers based on
circumstances in the host country must be approved by the Mission Director or other USAID
Principal Officers, see 1 CFR 700.16(j).

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SECTION G: FEDERAL AWARDING AGENCY CONTACT(S)

1. NOFO Points of Contact for questions, while the funding opportunity is open:

Sonia Madan
Acquisition & Assistance Specialist
USAID India
Email: smadan@[Link]

2. Acquisition and Assistance Ombudsman

The A&A Ombudsman helps ensure equitable treatment of all parties who participate in USAID’s
acquisition and assistance process. The A&A Ombudsman serves as a resource for all organizations
who are doing or wish to do business with USAID. Please visit this page for additional
information: [Link]

The A&A Ombudsman may be contacted via: Ombudsman@[Link]

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SECTION H: OTHER INFORMATION

USAID reserves the right to fund any or none of the applications submitted. The Agreement Officer
is the only individual who may legally commit the Government to the expenditure of public funds.
Any award and subsequent incremental funding will be subject to the availability of funds and
continued relevance to Agency programming.

Applications with Proprietary Data:

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 evaluation purpose, should mark the cover page with the following:

“This application includes data that must not be duplicated, used, or disclosed – in whole or in part –
for any purpose other than to evaluate this application. If, however, an award is made as a result of –
or in connection with – the submission of this data, the U.S. Government will have the right to
duplicate, use, or disclose the data to the extent provided in the resulting award. 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}.”

Additionally, the applicant must mark each sheet of data it wishes to restrict with the following:

“Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this
application.”

Additionally, the applicant must mark each sheet of data it wishes to restrict with the following:

“Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this
application.”

Additional information available to Applicants includes:

1. ADS [Link]; USAID’s Gender Equality and Female Empowerment Policy

([Link]

2. USAID India’s Country Development Cooperation Strategy [Link]

3. USAID’s Climate Change and Development Strategy 2012-2018 (2012).

([Link]

4. USAID’s Global Climate Change Initiative. ([Link] ).

5. USAID Standard Provisions: (i) ADS 303mab, Standard Provisions for Non-U.S. Non-
governmental Organizations. [Link] (ii)
ADS 303mab, Standard Provisions for U.S. Non-governmental Organizations.
[Link]

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6. Certifications, Assurances, Other Statement of the Recipient

(1) “Certifications, Assurances, Representations, and Other Statements of the Recipient” ADS
303mav document found at [Link]

(2) Assurances for Non-Construction Programs (SF-424B)

(3) Certificate of Compliance: Please submit a copy of your Certificate of Compliance if your
organization's systems have been certified by USAID/Washington's Office of Acquisition and
Assistance (M/OAA).

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ANNEXURE 1: STANDARD PROVISIONS

Mandatory Standard Provisions for Fixed Amount Awards to Nongovernmental Organizations

Note: The full text of these provisions may be found at:

[Link]
The award will include the latest Mandatory Provisions for fixed amount awards to non-U.S.
Nongovernmental organizations.

M1. SUBMISSIONS TO THE DEVELOPMENT EXPERIENCE CLEARINGHOUSE AND

DATA RIGHTS (JUNE 2012)
M2. MARKING AND PUBLIC COMMUNICATIONS UNDER USAID-FUNDED
ASSISTANCE (July 2015)
M3. DRUG TRAFFICKING AND DRUG-FREE WORKPLACE (JUNE 2012)
M4. DEBARMENT AND SUSPENSION (JUNE 2012)
M5. PREVENTING TRANSACTIONS WITH, OR THE PROVISION OF RESOURCES OR
SUPPORT TO, SANCTIONED GROUPS AND INDIVIDUALS (May 2020)
M6. TRAFFICKING IN PERSONS (April 2016)
M7. VOLUNTARY POPULATION PLANNING ACTIVITIES – MANDATORY
REQUIREMENTS (MAY 2006)
M8. EQUAL PARTICIPATION BY FAITH-BASED ORGANIZATIONS (JUNE 2024)
M9. USAID IMPLEMENTING PARTNER NOTICES (IPN) PORTAL FOR ASSISTANCE
(JULY 2014)
M.10 ENHANCEMENT OF GRANTEE EMPLOYEE WHISTLEBLOWER PROTECTIONS
(DECEMBER 2022)
M11. SUBMISSION OF DATASETS TO THE DEVELOPMENT DATA LIBRARY
(OCTOBER 2014)
M12. PROHIBITION ON REQUIRING CERTAIN INTERNAL CONFIDENTIALITY
AGREEMENTS OR STATEMENTS (MAY 2017)
M13. SAFEGUARDING AGAINST EXPLOITATION, SEXUAL ABUSE, CHILD ABUSE,
AND CHILD NEGLECT (OCTOBER 2023)
M14. MANDATORY DISCLOSURES (JUNE 2023)
M15. NONDISCRIMINATION AGAINST BENEFICIARIES (November 2016).
M16. CONFLICT OF INTEREST (August 2018)
M17. EXCHANGE VISITORS VISA REQUIREMENTS (DECEMBER 2022)
M18. OMB APPROVAL UNDER THE PAPERWORK REDUCTION ACT (OCTOBER 2023)
M19. LIMITING CONSTRUCTION ACTIVITIES (AUGUST 2023)

REQUIRED AS APPLICABLE STANDARD PROVISIONS FOR FIXED AMOUNT

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 NOFO No: 72038624RFA00004: Health Systems
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AWARDS TO NONGOVERNMENTAL ORGANIZATIONS

RAA1. FIXED AMOUNT AWARD ADVANCE PAYMENT AND REFUNDS (NOVEMBER

2020)
RAA2. UNIVERSAL ENTITY IDENTIFIER (UEI) AND SYSTEM FOR AWARD
MANAGEMENT (SAM) (DECEMBER 2022)
RAA3. REPORTING SUBAWARDS AND EXECUTIVE COMPENSATION (DECEMBER
2022)
RAA4. USAID ELIGIBILITY RULES FOR PROCUREMENT OF COMMODITIES AND
SERVICES (MAY 2020)
RAA5. FLY AMERICA ACT RESTRICTIONS (AUGUST 2013)
RAA6. OCEAN SHIPMENT OF GOODS (JUNE 2012)
RAA7. REPORTING HOST GOVERNMENT TAXES (DECEMBER 2022)
RAA8. PATENT RIGHTS (DECEMBER 2022)
RAA9. [RESERVED]
[Link] PROMOTION (DECEMBER 2022)
[Link] OF HUMAN RESEARCH SUBJECTS (JUNE 2012)
RAA12. STATEMENT FOR IMPLEMENTERS OF ANTI-TRAFFICKING ACTIVITIES ON
LACK OF SUPPORT FOR PROSTITUTION (JUNE 2012)
RAA13. ELIGIBILITY OF SUBRECIPIENTS OF ANTI-TRAFFICKING FUNDS (JUNE 2012)
RAA14. PROHIBITION ON THE USE OF ANTI-TRAFFICKING FUNDS TO PROMOTE,
SUPPORT, OR ADVOCATE FOR THE LEGALIZATION OR PRACTICE OF PROSTITUTION
(JUNE 2012)
RAA15. VOLUNTARY POPULATION PLANNING ACTIVITIES – SUPPLEMENTAL
REQUIREMENTS(JANUARY 2009)
RAA16. CONSCIENCE CLAUSE IMPLEMENTATION (ASSISTANCE) (FEBRUARY 2012)
RAA17. CONDOMS (ASSISTANCE) (SEPTEMBER 2014)
RAA18. PROHIBITION ON THE PROMOTION OR ADVOCACY OF THE LEGALIZATION
OR PRACTICE OF PROSTITUTION OR SEX TRAFFICKING (ASSISTANCE) (SEPTEMBER
2014)
RAA 19. METRIC SYSTEM OF MEASUREMENT (AUGUST 1992) ]
[Link] TO USAID FACILITIES AND USAID’s INFORMATION SYSTEMS
(AUGUST 2013)
[Link] ON SUBAWARDS TO NON-LOCAL ENTITIES (JULY 2014)
[Link] TERM AND CONDITION FOR RECIPIENT INTEGRITY AND
PERFORMANCE MATTERS (DECEMBER 2022)
[Link]

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[Link] ON CERTAIN TELECOMMUNICATION AND VIDEO

SURVEILLANCE SERVICES OR EQUIPMENT (DECEMBER 2022)
RAA25. NEVER CONTRACT WITH THE ENEMY (NOVEMBER 2020)

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ANNEXURE 2:PRELIMINARY GENDER EQUALITY AND SOCIAL INCLUSION

ANALYSIS

I. Background

The goal of USAID's Gender Equality and Women's Empowerment 2023 (GEWE 2023) policy
and the Agency's implementation guidance in ADS 205 is to build a peaceful and prosperous world
in which women and girls, men and boys, and gender-diverse individuals, throughout their lives,
enjoy equal rights; have the agency to secure better lives for themselves, their families, their
communities, and their countries; have equitable access to high-quality education and health care,
as well as justice and economic opportunity; accumulate and control their own assets and
resources; exercise their own voices; and live free from restrictive gender norms, beliefs, and
practices, including intimidation, harassment, discrimination, and violence. USAID's programs
address the needs of and benefit all people inclusive of ethnicity, gender identity and expression,
sex characteristics, sexual orientation, income level, disability, and other factors.
Pursuant to ADS 205.3.1 and in alignment with the USAID Gender Equality and Women's
Empowerment Policy, Operating Units (OU) are responsible for conducting gender and inclusive
development analyses at the design stage of a new activity and for ensuring that the Policy is
implemented throughout each stage of the Program Cycle.

Differences in power, status, and gender norms and relations affect people's ability to participate
in and benefit from proposed activities, especially groups that are particularly disadvantaged or
that have strong unmet needs for empowerment (e.g. lesbian, gay, bisexual, transgender, and
intersex (LGBTQI+) persons, youth, ethnic minorities, persons with disabilities, indigenous
communities, the elderly, and other socially relevant categories).
In 2021, the Biden-Harris Administration released the first-ever United States Government
National Strategy on Gender Equity and Equality (strategy). The strategy reflects a commitment
to address gender broadly, with a commitment to women and girls, in light of longstanding
systemic discrimination and barriers which continue to affect their full participation and access to
opportunity. Under the strategy, USAID combats discrimination and harmful gender norms that
affect people of all genders: women and girls- including transgender women and girls-gender
nonbinary and gender nonconforming people, as well as men and boys.
The strategy also addresses the impact of intersectional discrimination and bias based on gender,
race, and other factors, including sexual orientation, ethnicity, religion, disability, age, and
socioeconomic status. Under the strategy, programs and approaches will be informed by the
historical and current context of these overlapping burdens.
This Health Systems Strengthening Activity will also align its activity implementation with
USAID's Policy Paper on Disability (being updated), Promoting the Rights of Indigenous Peoples
2020 Policy (PRO-IP Policy), LGBTQI+ Policy and Youth Policy 2022. The Policies reflect

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USAID's commitment to supporting inclusive and sustainable development and advancing human
dignity by protecting and empowering every social segment of the society. These policies position
USAID to strengthen and expand upon decades of support it has committed to marginalized and
underrepresented groups around the world. These policies offer guidance on the robust
engagement and partnership with these groups to help USAID programs align with the
communities' own development priorities and ensure that USAID staff and implementing partners
safeguard against unintended, adverse impacts.
Although women tend to live longer because of biological and behavioral aspects of being
female15, it hides the disproportionate number of deaths among young and adult women in
Asia16. Contributors to poor health outcomes among women in South Asia include gender-based
discrimination in breastfeeding, food allocation, immunization, access to health care services,
and finances available to pay for treatment17. South Asia is also known for gender-based
discrimination in abortion, nutrition, and access to health care18.

15
Barford, A., Dorling, D., Smith, G. D., & Shaw, M. (2006). Life expectancy: Women now on top everywhere:
During 2006, even in the poorest countries, women can expect to outlive men. BMJ British Medical Journal,
332(7545), 808. Also, Seifarth, J. E., McGowan, C. L., & Milne, K. J. (2012). Sex and life expectancy. Gender
Medicine, 9(6), 390–401.
16
Anderson, S., & Ray, D. (2012). The age distribution of missing women in India. Economic and Political Weekly,
6(47–48), 87–95, 47. Bongaarts, J., & Guilmoto, C. Z. (2015). How many more missing women? Excess female
mortality and prenatal sex selection, 1970–2050. Population and Development Review, 41(2), 241–269. Khanna, R.,
Kumar, A., Vaghela, J. F., Sreenivas, V., & Puliyel, J. M. (2003). Community based retrospective study of sex in
infant mortality in India. BMJ, 327(7407), 126. Office of the registrar general (ORG). (2014). Sample registration
system statistical report 2013. Ministry of home affairs government of India, report no. 1 of 2014. Available at:
[Link] Saikia, N., Moradhvaj, & Bora, J. K. (2016).
Gender difference in health-care expenditure: Evidence from India human development survey. PLoS One, 11(7),
e0158332; and also Sudha, S. S. I. R., & Rajan, S. I. (1999). Female demographic disadvantage in India 1981–1991:
Sex selective abortions and female infanticide. Development and Change, 30(3), 585–618.
17
Asfaw, A., Klasen, S., & Lamanna, F. (2007). Intra-household gender disparities in children's medical care before
death in India. Institute for the Study of Labor (IZA). Discussion Paper; 2007, (2586). Borooah, V. K. (2004).
Gender bias among children in India in their diet and immunisation against disease. Social Science & Medicine,
58(9), 1719–1731. Gupta, M. D. (1987). Selective discrimination against female children in rural Punjab, India.
Population and Development Review, 77–100. Kurz, K. M., & Johnson-Welch, C. (1997). Gender differences
among children 0–5 years: An opportunity for child survival interventions. A review paper prepared for the BASICS
project. USAID/BASICS II, Arlington, VA. Pande, R. P. (2003). Selective gender differences in childhood nutrition
and immunization in rural India: The role of siblings. Demography, 40(3), 395–418. Rajeshwari. (1996). Gender
bias in utilisation of health-care facilities in rural Haryana. Economic and Political Weekly, 489–494. Roy, K., &
Chaudhuri, A. (2008). Influence of socioeconomic status, wealth and financial empowerment on gender differences
in health and health-care utilization in later life: Evidence from India. Social Science & Medicine, 66(9), 1951–
1962. Singh, A. (2012). Gender based within-household inequality in childhood immunization in India: Changes
over time and across regions. PLoS One, 7(4), e35045. Singh, P. K. (2013). Trends in child immunization across
geographical regions in India: Focus on urban-rural and gender differentials. PLoS One, 8(9), e73102. Song, Y., &
Bian, Y. (2014). Gender differences in the use of health-care in China: Cross- sectional analysis. International
Journal for Equity in Health, 13(1), 8.
18
Arnold, F., Choe, M. K., & Roy, T. K. (1998). Son preference, the family-building process and child mortality in
India. Population Studies, 52(3), 301–315. Fledderjohann, J., Agrawal, S., Vellakkal, S., Basu, S., Campbell, O.,
Doyle, P., et al. (2014). Do girls have a nutritional disadvantage compared with boys? Statistical models of
breastfeeding and food consumption inequalities among Indian siblings. PLoS One, 9(9), e107172. Guilmoto, C. Z.,
Saikia, N., Tamrakar, V., & Bora, J. K. (2018). Excess under-5 female mortality across India: A spatial analysis
using 2011 census data. The Lancet Global Health, 6(6), e650–e658.

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Studies in India show that health care expenditure (HCE) was systematically lower for women
than for men across all socioeconomic subgroups, despite women having a higher prevalence of
morbidity than men19. A study on HCE and health care financing (HCF) by households in India,
based on National Sample Survey of India database20, show that healthcare expenditures in
hospitalization was systematically higher among male patients than female patients across
demographic and socioeconomic characteristics, although the extent of this difference varies by
group. The absolute and relative gaps in HCE by gender were higher among older adults (age 60
years and older), among non-Hindu patients, and among patients belonging to the richest wealth
quintile. The study observed the absence of a gender difference in HCE only in the case of
communicable diseases. Average HCE on doctor fees, medicine costs, diagnostic test costs, and
costs of other medical items for inpatients are invariably higher among men than women. The
study further examined the association between gender and HCE, after adjusting for the effects
of other variables, and found that women were facing discriminatory behavior in health care
spending for inpatient care. When the study further delved into how this HCE was financed, it
found that there was a systematic variation in the different financing strategies between men and
women regardless of background characteristics. The percentage of men hospitalized using
distressed financing was higher than that of women regardless of background characteristics.
Although there was no substantial difference in the HCF pattern between inpatients belonging to
the Hindu and Muslim religions, the percentage of patients using distressed financing was lower
among those belonging to other religions. As the economic status of the household increased, the
percentage share of income or savings increased to finance the HCE. The percentage shares of
distressed HCF were high for noncommunicable diseases and private health care facilities. The
average transportation costs and doctors' fees were high in all types of distressed HCF. The study
further delved into the association between gender and sources of HCF, after adjusting for the
role of demographic, socioeconomic, and other health-related characteristics, and found that the
probability of hospitalization was lower among women, with respect to all sources of HCF, even
after controlling for the role of demographic, socioeconomic, and health-related variables. The
study then goes on to postulate that women have less chance of using hardship financing for
inpatient care. Therefore, there is an urgent need to introduce gender-inclusive social health
security and micro-insurance schemes in India. At the same time, it is also necessary to empower
women by engaging them in economic activities to reduce gender-based discrimination in health
care.

19
Batra, A., Gupta, I., & Mukhopadhyay, A. (2014). Does discrimination drive gender differences in health
expenditure on adults: Evidence from cancer patients in rural India. Indian Statistical Institute Discussion Paper,
(14-03). Maharana, B., & Ladusingh, L. (2014). Gender disparity in health and food expenditure in India among
elderly. International Journal of Population Research, 2014. Saikia, N., Moradhvaj, & Bora, J. K. (2016). Gender
difference in health-care expenditure: Evidence from India human development survey. PLoS One, 11(7), e0158332.
20
Saikia, N., 2019. Gender disparities in health care expenditures and financing strategies (HCFS) for inpatient care
in India. SSM-population health, 9, p.100372.

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Several schemes by the Indian government have been enacted to lower OOPEs and increase
accessibility to healthcare for citizens but public health facilities are widely understaffed,
underfunded, and unhygienic and gendered issues go largely unacknowledged among
government programs and vary tremendously based on the state. In 2008 the National Health
Insurance Program (Rashtriya Swasthyma Bima Yojana, or RSBY) was launched in order to
mitigate health shocks by insuring people Below Poverty Line (BPL). By 2016, 41 million
families were enrolled in RSBY, but the scheme did not successfully reduce OOPE as desired
and was later subsumed under the Pradhan Mantri Jan Ayogya Yojana (PM-JAY). PM-JAY, a
key component of Ayushman Bharat, the government's health assurance plan, offers a Rs
500,000 coverage for a hospital stay for 40 percent of India’s population that is below the
poverty line . This does not, however, cover the costs of transport, drugs or outpatient services.
Ayushman Bharat also has a key pillar focused on transforming existing PHCs and sub-centers
into Health and Wellness Centers to bring comprehensive primary care closer to rural villages.
Several schemes including the National Health Protection Scheme focuses efforts to provide
coverage to low income families in India, but there is a need to look at the effects of these
programs through an intersectional lens as accessibility, treatment, care, and illness affect
different gendered and classed people in widely varying ways. Funding and access are not the
only issues that prevent women and non-men from accessing treatment; approaches to
strengthening health systems must transform patriarchal norms so that women can have a greater
control of their own health and limit the stigma and discrimination faced from the health sector
and communities.

Previous health gender analysis findings confirm that patriarchy and deeply entrenched social
norms and beliefs in India perpetuate gender, caste, class, tribal, age, gender identity, and
disability inequalities that impede health care access21. Women and girls do not hold decision
making power in the household in most areas thus often they are not in charge of their own
health and accessing their own health needs. Son and male preference make men more likely to
access higher quality health care and sooner than women with 37 percent of women accessing
health care compared to 67 percent of men. Women in all their diversity found the most
hindering components to accessing healthcare, in descending order, were lack of medicines, lack
of (female) health care providers, distance to facilities, and lack of money. Additionally,
intersections of race, caste, ability, class, and other identities increase discrimination, stigma, and
abuse received in medical facilities that especially deters disabled women. LGBQ+ individuals
and transgenders from accessing healthcare. COVID 19 affected women workers the most by
higher unemployment and wider layoffs for female workers, a higher burden of care at home,
and increased hours without increased pay for frontline health workers who are primarily
women; all of these effects of COVID not only result in increased domestic Gender Based
Violence (GBV) and less financial and social freedom for women, but also limit their access to
healthcare by removing employer covered insurance and increase of unpaid domestic labor

21
Messner, Lyn. Rapid Gender Analysis For The Health Project Appraisal Document.

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leaving little time and ability to go to health facilities. Gender development is needed within the
health sector and is proven to contribute to economic and social development so, gender equality
means overall greater development.

The main areas of need in health that are addressed under this activity are TB, Maternal and
Child Health (MCH), Family Planning (FP), and strengthening health systems to withstand
health and climate shocks through integrated service delivery mechanisms and private sector
partnership. Gender is a key component in all these areas which dramatically affects care and
ability. Reproductive health problems and limited access to services remain the leading cause of
ill health and death for women of childbearing age who suffer disproportionately from
unintended pregnancies, maternal death and disability, and sexually transmitted infections.
Women in tribes and scheduled castes are particularly at risk from low health seeking behavior
and lack of accessible resources resulting in 50 percent of all maternal deaths in the country
occurring in women from 56 scheduled castes that make up just 16.67 percent of all women in
India. Educational awareness for sexual and reproductive health (SRH) is much lower in women
compared to men and although India has the third largest HIV epidemic in the world women are
less likely to know where to get tested or have general knowledge about HIV. Pregnant women
with HIV are also more likely to contract TB during pregnancy and after birth. TB is known as a
“men’s disease” and is more prevalent in men; however, TB is the fifth leading cause of death in
women and is difficult to diagnose in women leading to them being underdiagnosed and less
likely to be treated. Additionally, social stigma is much greater for women with TB than men
which limits access and health seeking behavior as a TB diagnosis could limit a woman’s
marriage opportunities. Health systems are needed to be strengthened through a greater
distribution of funds to the public health sector, gender inclusive programming and training,
more accessible health care centers in rural and tribal areas, and inclusion of women and gender-
diverse individuals in decision making roles to mitigate the above health shocks that have been
heightened by COVID-19 and the climate crisis.

USAID/India will focus its efforts in India around strengthening the enabling environment across
the socio ecological model. Health services must be tailored to the needs of individuals and their
communities. Health systems are evolving to embrace a person centered approach that is focused
on meeting the individual needs of each person so that they are able to access timely, quality
diagnosis, care and treatment in a supportive environment that is based on respect for the patient
autonomy, physical comfort and psychosocial support. In order to address gender and social
inequities, programs under the project will be expected to:

● Gain an understanding of gender relations, the division of labor, and who has access to
and control over resources;
● Use participatory processes and include a wide range of female and male stakeholders at
the governmental level and from civil society, including organizations working on the

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issues of women, youth, persons with disabilities, LGBTQI+ persons, and gender and
social inclusion experts;
● Identify and be sensitive towards issues of disability and of transgenders, considering the
intersecting marginalization imposed by caste and racial origin
● Identify barriers to women’s participation;
● Gain an understanding of women’s health needs and strategic interests, and identify
opportunities to support both;
● Gain an understanding of the differences in exposure among the genders, identifying
settings that may put men as special risk (e.g., mines and prisons);
● Consider the differential impact of the initiative on women,men and gender-diverse
individuals and identify consequences to be addressed.

It is important to note that a gender and inclusive development analysis considers the different
and intersectional threats, impacts, and opportunities of learners with disabilities, girls and boys
included, in all their diversity and marginalized populations, including religious minorities,
Schedule Castes (SC), Scheduled Tribes, other backward castes (OBC), youth, and Lesbian, Gay,
Bisexual, Transgender, Queer, and Intersex persons (LGBTQI+). As such, this initial analysis
considers gender and inclusive development issues throughout the various stages of the Program
Cycle – from activity design and implementation, monitoring and evaluation (M&E), and
learning and adapting.

The nature and magnitude of gender-related disparities in health systems among women and men
in India include:
● Female migrants being more susceptible to GBV, exploitation, and infectious diseases
from poor living and working conditions
● Women's literacy rate at 65.79 percent compared to men’s 82.37 percent reflecting lower
enrollment of women and their access disparity to media and education
● Utilization of health care services by women migrants and transgenders indicated low
utilization of ANC services, poor access to maternal healthcare, low rate of vaccination
and low institutional delivery among pregnant groups in urban centers
● TB stigma affecting the social standing and health seeking behavior of women and
gender-diverse individuals in comparison to men.

II. Activity Design

This Health Systems Strengthening (HSS) activity aims to transform USAID’s traditional
assistance to the Government of India (GoI) on cross-cutting health systems strengthening,
signaling the transition in the US India partnership in health by strengthening platforms and
institutions in the public and private sector to accelerate and scale innovative development
approaches that are inclusive, sustainable and leverage digital health technologies. The purpose

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of the activity is to accelerate and scale up, and not incubate and seed, innovative approaches to
increasing access and reducing out-of-pocket expenditure on healthcare in India. This activity
will focus on vulnerable and marginalized communities in India, including those in urban areas,
with the aim of expanding equitable access to comprehensive primary healthcare, strengthening
the continuum of care, and advancing progress towards universal health coverage. This
acceleration of innovative models and approaches, especially in the private sector, will be
assisted by risk underwriting from the US International Development Finance Corporation
(DFC) and other bilateral/multilateral financial institutions.

This activity will move away from traditional models of assistance and focus on building and
growing connections between government institutions and systems, existing platforms within the
private sector, and networks of nonprofit entities and community based organizations. The
activity will also explore how experience and innovations from India can strengthen
comprehensive primary healthcare (CPHC) around the world, adopting a platforms-based
approach to take Indian healthcare innovations to other partner countries globally.

III. Existing Gender Assessments

In 2019, a Mission-wide gender analysis was conducted while formulating the USAID/India 2020-
2025 CDCS. Though the Mission strategy is updated, the findings for the HSS still remain valid.

In 2021, PAD level Health Gender analysis was conducted with a deep focus on HSS. The
document also presents case studies and success stories that demonstrate how integrating gender
concerns in the overall health framework of any project is beneficial for all. Prospective partners
should refer to this analysis to get a deep understanding of health and gender issues in India.

In 2021, an Inclusive Development Assessment Report was also conducted to better understand
the development gaps for marginalized and under-represented groups.

IV. Main Findings by Domain

Laws, Policies Regulations and Institutional Practices

National policies and laws are an important part of transforming social and cultural norms
towards equality and strengthening the health systems and infrastructure to be available to
everyone. The Government of India (GOI) with USAID/India is moving away from a linear
approach to health and towards a human centric approach which will enable continuous
improvements in health for citizens of India. The diversity of India and the ways health policies
are implemented by state means projects aimed at strengthening health systems not only have to
look at the federal level, but also the ways in which policies can be implemented in individual
states and what the needs are in different areas for different populations. This analysis focuses on
indigenous communities, internal migrants in urban areas, and the populations in Northeastern
states.

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There has been an increase in legal protection for women in the workplace and laws on
harrassment and rape have been put in place. Additionally, India’s constitution guarantees the
right to equality under Article 14, 15, and 16 and the Right of Persons with Disabilities Act of
2016 prohibits discrimination of persons with disabilities in the private sector22. Through the
creation of incentives and updated policies the GOI has taken steps to increase women's
participation in the workforce.

The GOI has instituted some programs to strengthen the health sector, but there is a need for
updates and initiatives targeting marginalized people. One of the largest government schemes is
the Ayushman Bharat health assurance plan that the GOI with NHP instituted in 2018 to reduce
OOPEs to support India’s poorest citizens and create Health and Wellness Centers (HWC) that
provide free high-quality and comprehensive care. Additionally, the Development of Women
and Children in Rural Areas (DWRCA) was created in 1982 and updated in 1994 to empower
poor women in rural areas through greater access to credit, education, and health services23.
Limited programs have been instituted for gender development in the health sector.

Even with an increase of legal protections, there must be stricter legislation in areas like forced
child marriage and harassment. India has the highest rates of child marriage in the world with
over 15 million child brides; laws pertaining to gender based violence (GBV), forced child
marriage, and harrassment are not strictly enforced. This vulnerability to violence and lack of
autonomy, which could be reduced through comprehensive legislation, enforcement, and
transformation of gender norms, impedes women's rights and creates unsafe conditions for
women, girls, and children. For migrants in urban pockets institutional failures such as
substandard health infrastructure at primary and secondary levels, lack of specific strategies, and
complex administrative procedures hinder access and contribute to their unsatisfactory health
status24.

Access to and Control over Assets and Resources

Women-headed households, and rural and poor women, have less access to health insurance and
financing than men; lower caste women and women with disabilities are even further
disadvantaged. People in the low income group are less likely to take time off for illness due to a
loss of wages and women are less likely to take care of their own wellbeing over the household.
Health facilities hours are not compatible with people who work full days, which further burdens
lower income people. This poor health seeking behavior, lack of financing, and lack of

22
Gire, Cynthia. HSS New Design Activity 2023. USAID/India, 1 February, 2023
23
Acharya, Mayashree. “Development of Women and Children in Rural Areas.” cleartax, 21 April, 2022,
[Link]
24
Puja Krishna and Aditya Raj. Health Condition of Internal Migrants in India: A Review. Indian Journal of
Human Development, 2022, [Link]

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opportunity limits women's and low income people’s ability to access proper healthcare.

Most migrants work in the informal sector and live and work in poor conditions that lack basic
amenities such as water and safe and sanitary conditions which expose them to infectious
diseases. Their migrant status strips them of access to universal health coverage and social
services. Women migrants reported low utilization of ANC services, poor access to maternal
healthcare, low rate of vaccination, and low institutional delivery among pregnant groups in
urban centers. Working conditions and low socio-economic status makes female migrants at risk
of poor pregnancy, infectious diseases, and other work related health issues that cannot be
addressed without legal access to resources and awareness on rights and programs in place.

Gender Roles, Responsibilities, and Time Use

COVID-19 has affected women's roles in health with resources being diverted to the pandemic
there are less services and resources for women's reproductive health. COVID-19 negatively
impacted women's employment by wider layoffs which took away women's employer provided
health insurance and financial freedom with studies showing women's jobs taking the longest to
recover after the pandemic. Additionally frontline workers, who are majority women, and
ASHAs, female community health care workers, have been taking a higher workload throughout
the pandemic, increasing risk of infection, and have not received a reflected increase in pay.
Although GOI is working to address this inequality, the COVID-19 response has increased
ASHAs’ workload, stigma, and susceptibility to GBV. Although COVID-19 has exacerbated
issues of women’s roles in healthcare, regardless of the pandemic a minimum of 6 million
women work unpaid or grossly underpaid in core health system roles and act as a critical
interface between health systems and communities25.

Women are expected to take on unpaid domestic and emotional labor as well as unpaid health
care work at the household and community level because of a perception that women are natural
caregivers and self-sacrificing, a dangerous patriarchal myth that dismisses women’s needs and
leads to less economic security and freedom for women. Community health work can empower
women, but by being unpaid or underpaid it keeps low income women in poverty and adds to
their workload without compensation. Despite being 75 percent of the health workforce women
makeup only 25 percent of leadership roles26. Girls must be enabled to finish secondary school
and women in healthcare roles should be given training and offered formal sector jobs that can
create careers and lift them out of poverty.

A major proportion of female migrant workers, without social security, health coverage, and

25
Keeling, Ann. “Women’s unpaid work in health systems: the myth of the self-sacrificing gene.” thebmj, BMJ, 7
July 2022, [Link]
26
Subsidizing Global Health: Women’s Unpaid Work In Health Systems. Women in Global health, June 2022,
[Link]

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welfare schemes due to undocumented status, face exploitation and harassment by contractors in
the workplace27. Their status leaves them vulnerable to unsafe and unsanitary working conditions
and harassment which also increases their likelihood of contracting occupational or infectious
diseases. Major health concerns for women in their roles as workers and in the household are
risks associated with pregnancy, maternal health, childbirth, prevalence of moderate to severe
anemia, increased threat of RTI or STI, problems of sexual dysfunction and violence and spousal
abuse. Migrants in host cities lack their regular support system and for women that means a
greater risk of domestic GBV without support or paths out, greater risks to pregnancy and lack of
access to antenatal care. A greater awareness of services available to female migrants, especially
related to pregnancy and maternal care, is necessary to increase access and overall health of
migrant populations.

Although matriliny in the Northeast is common, that does not give women advantages such as in
Meghalaya, which has the third highest rates of teenage pregnancy in India at 53 percent28. The
matrilineal organization of society means that young women are likely to drop out of school
when pregnant, expected to support and run their families single handedly.. With lower nutrition
and higher rates of anemia than men in the northeast, women’s health is still not prioritized while
holding the majority of responsibility in the household without the privileges available to men
such as access to education, credit and loans. Financial freedom and awareness of government
schemes to aid women and single mothers in accessing healthcare and finances would be
beneficial to this area and population of women.

Cultural Norms and Beliefs

India has the third largest HIV epidemic in the world and HIV prevention has high political
support across the country, but there is still an extreme stigma for women. Gay men, transgender
women, women living with HIV, and commercial sex workers remain extremely marginalized
and face widespread stigma, homophobia, and discrimination, which prevents them from
accessing HIV services and makes them more vulnerable to HIV infection29. Although 90
percent of women with HIV are infected by their husbands, women face discrimination and
stigma for their status being equated to immoral behavior, which limits their access and
adherence to antiretroviral treatment (ART). women also have less ability to advocate for their
sexual safety and health because of GBV or threat of GBV. Additionally, transgender women
face high rates of sexual violence that increases their HIV risk and stigma and discrimination at
health facilities which constrains access to HIV diagnosis, treatment, and care. Women with
disabilities are also vulnerable to sexual violence, forced medical procedures, and

27
Puja Krishna and Aditya Raj. Health Condition of Internal Migrants in India: A Review.
28
Dang, Geetika. “Assessing Gender in the North East.” Brookings, 2 September 2019,
[Link]
29
Messner, Lyn. Rapid Gender Analysis For The Health Project Appraisal Document.

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institutionalization. For migrant workers there is a higher risk of HIV/AIDS than their non-
migrant counterparts and wives of migrant men have an increased risk of HIV than the general
population of women in rural North India30. Studies also show a higher risk of RTI or STI among
women migrants in metropolitan areas with about 36.4 percent of migrants in Mumbai and 14.8
percent in Delhi reporting symptoms of RTI/STI. Sexual and reproductive health awareness,
women's health clinics, and support systems put in place for women and gender non-conforming
identities could empower these populations to make their own health decisions, be informed on
their sexual health, and provide access to ART and other treatments.

TB particularly affects the urban poor, migrants, persons with disabilities, people living with
HIV, people engaged in mining and industrial activity, scheduled tribes, and people with drug
resistant TB because they are at higher risk of negative treatment outcomes31. Women face
higher TB stigma than men who are more likely to be diagnosed. Women are more likely to take
care of a spouse with TB while a woman with TB is more likely to be divorced or sent away for
treatment. The GOI has implemented a national anti-stigma campaign for TB and continues to
put efforts into this social and health issue.

Scheduled caste women represent 16.67 percent of all women in India yet make up almost 50
percent of all maternal deaths and urban poor women access antenatal care (ANC) the least. The
under-five mortality rate for scheduled tribes is 75 percent higher than the rest of the population.
Around 79 percent of women deliver at health facilities with much lower rates in Nagaland (32.8
percent), Meghalaya (51.4 percent), and Arunachal Pradesh (52.2 percent)32. The most common
reason for women not to deliver in a health facility was that she did not think it was necessary
(40 percent), distance or lack of transportation (18 percent), husband or family did not allow
delivery in a health facility (18 percent), and cost (16 percent). There is a clear disparity in the
maternal care afforded to urban poor women and scheduled caste women in India that results in
higher risk of complications. In the Northeast female child mortality is higher than males with
the highest disparity in Nagaland with a rate of 15 for men and 26 for women. Transportation
costs to get to a delivery institution are especially high for scheduled tribe women at 416 rupees
compared to 90 rupees for non-scheduled tribes. Migrant women have poor socio-economic
status in the individual and household levels, which results in a higher vulnerability to sexual
abuse, exploitation, and other forms of violence33. The threat of maternal mortality is found to be
more amongst internal migrant women than with permanent resident women due to less access to
healthcare in host cities and lack of knowledge on available services. Reverse migration occurs

30
Puja Krishna and Aditya Raj. Health Condition of Internal Migrants in India: A Review.
31
Messner, Lyn. Rapid Gender Analysis For The Health Project Appraisal Document.
32
Kumbang, Sonali Chakraborty. Gender Inequality in North East India. International Journal of
Humanities and Social Science Invention, April 2020, [Link]
1/[Link]
33
Puja Krishna and Aditya Raj. Health Condition of Internal Migrants in India: A Review.

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when pregnant migrant women return to their villages where they have support to give birth, but
often they miss services like ANC in their host cities and services in their village because of the
journey. Female migrants in Mumbai report low utilization of ANC services and a high
proportion of home deliveries with 12 percent of home deliveries facilitated by untrained Dai
despite reproductive and child health programs. A recent study in Ahmedabad showed only 32
percent of the women had received two or more ANC check-ups, 64 percent had had an
institutional delivery and 62 percent had received postpartum care within two days of childbirth.
Women have indicated that their access to seek healthcare services in the city was restricted due
to time constraints, inability to take a break from work, irregular wage patterns and lack of
awareness about urban health systems.

The socio-cultural preference for having sons and prioritization of the wellbeing of men over
women often results in higher nutrition and easier access to high quality healthcare for men than
women and children. Masculine and feminine norms result in greater discrimination for
transgender women who are vulnerable to harassment and assault. Additional norms and social
influences that affect women and their access to healthcare are language and literacy, family
responsibilities, confidentiality, HIV increases vulnerability to TB, pregnancy and childbirth, and
social stigma.

Patterns of Power and Decision-making

Within the household women hold less decision-making power and are dependent on the men in
the family for their health and well-being while being the least likely to be prioritized. Women
and girls have less privacy in their health experiences because they are often chaperoned to
doctor’s visits, which limits their ability to receive comprehensive sexual health care. Women
overall have less awareness of their rights and health needs that puts them at a greater risk of
infectious diseases and STIs.

In the health sector women makeup the majority of field staff and frontline workers, yet men are
the majority in supervisory positions. There is a need to uplift women throughout the health
sector to decision-making roles and having women involved in every level, so that health needs
are being addressed by and for women.

V. Analysis of Issues and Recommendations by Technical Component

The table below provides an overview of the activities that will be implemented under the
activity technical components. For those activities where gender and social inclusion issues
have been identified, the table presents recommended actions that will be taken to ensure gender
equity remains at the forefront of the activities’ design, implementation, and M&E. The
integration of gender and social sensitivity into the proposed technical approach is part of the
evaluation criteria for the program. In addition, the Awardee will be obligated to draft a gender

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and social integration plan with quantitative data for the geo locations where the activity will be
implemented within 90 days of initiating the award.

Result Areas of the Activity Potential Gender Issues and Recommendations, Specific
Relevance to the Activity Actions, and General
Considerations

1. Increased access to Access to high quality healthcare The project will prioritize
integrated primary for women, both in government scaling up high-quality,
healthcare and wellness for and private health facilities, is comprehensive, low cost,
marginalized groups
constrained by time and cost home-based or near-to-home
including those in both rural
and urban areas across their considerations. healthcare and wellness models
lifespan and approaches, specifically
(Level of effort - 30%) targeted at women, and other
underrepresented and
2. Assured continuity of care underprivileged communities.
within and between
primary, secondary and
tertiary healthcare services
(Level of effort - 20%)

3. Strengthen public-private Although women access more The activity will work with city
integration to boost access, private healthcare, especially in and state governments for
affordability and quality of urban areas, because of increased strengthening public-private
care availability of such facilities, the partnerships and strategic
(Level of effort - 20%) wide variation in quality and high purchasing models for ensuring
cost restricts their access to higher quality and affordable
comprehensive care leading to healthcare, especially for
suboptimal health outcomes. comprehensive primary
healthcare, targeted at women,
people with disability and other
marginalized populations.

4. Increased supply side Disproportionate use of distress The activity will test models of
efficiency and demand-side financing for men's healthcare financial risk protection
financial risk cover, indicates women, children and the especially targeted at special
especially for primary elderly foregoing required care health needs of women and
health care, in public and because of financial other marginalized
private health systems considerations. communities, both as publicly
(Level of effort - 20%) subsidized models as well as
low-cost business models.

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5. Increased adaptation and Public and private health systems, The activity will prioritize
mitigation of climate and already constrained by limited providing support to public and
environmental shocks financing, generally lack resources private primary and secondary
affecting the health system to adapt to emerging climate level facilities that are accessed
(Level of effort - 10%) challenges like health and air more by women, people with
pollution. Women, children, disabilities and other
elderly persons, migrants, persons marginalized communities, for
with disabilities, scheduled castes, increased adoption of climate
scheduled tribes and other under- resilient facility design and
represented groups are more equipment and supplies.
impacted because of this as they
end up accessing the low-level
public and private facilities that
are near their homes and are less
costly.

[END OF ANNEXURE 2]

[END OF ANNEXURES]

- END OF NOFO NO. 72038624RFA00004 -

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