Context

Nutrition International (NI), formerly the Micronutrient Initiative, is a global leader in nutrition. For 30 years, NI has worked with a wide range of donors, governments, UN agencies, civil society, research institutions and other partners across the world to promote, accelerate and facilitate the scale-up of high-impact nutrition interventions within health, food, and education systems. NI works as an ally to the government to implement nutrition interventions and solutions to malnutrition – including micronutrient deficiencies – through different programs. NI also conducts high quality implementation research, incorporating the skill sets of a diverse and dynamic group of technical experts in public health, nutrition, and research.

In 2007, NI was established in Nigeria and has become a trusted partner of the government and a leader in addressing the burden of malnutrition in the country. Aside from nutrition interventions benefiting a broader population (vitamin A supplementation for children under five, zinc and oral rehydration salts (ORS) for treating diarrhea, and expanding knowledge and awareness about nutrition among vulnerable adolescent girls and women), one of NI’s key aims in Nigeria is to improve the nutrition, health, and survival of pregnant women and newborns. Since 2016, NI has been supporting maternal health and nutrition programming in five northern states (Sokoto, Yobe, Katsina, Jigawa, and Kebbi) and more recently Cross Rivers to: improve access to and utilization of antenatal care (ANC) and postnatal care; increase coverage of nutrition interventions, including IFA supplementation; and strengthen quality of care with an emphasis on gender equality and family engagement.  

Project Rationale

ANC has been recognized as a strategic platform for delivery of services, health promotion, and disease prevention. In July 2020, WHO’s recommendation on multiple micronutrient supplementation (MMS) – a daily dose of 15 vitamins and minerals including iron and folic acid – during pregnancy was updated in response to new evidence that showed that MMS was more effective than iron-folic acid (IFA) supplementation in improving birth outcomes, had equivalent benefits for preventing maternal anemia, and was safe for mother and baby.  The updated WHO guidelines encourage low- and middle-income countries (LMICs) that are considering transitioning from long-standing IFA supplementation to MMS in the government’s ANC service package to do so in the context of rigorous research. Specifically, the WHO guidelines recommend implementation research where MMS programs are being considered to optimize the impact of switching from IFA to MMS such as an evaluation of acceptability, feasibility, sustainability, equity, and cost-effectiveness. At an operational or programmatic level within each country, the recommendation means introducing MMS in conjunction with implementation research to ensure effective implementation, the lessons from which are used to inform future scaling of MMS within existing ANC services. Moreover, for MMS to be effective, pregnant women must consume the right dose at the right time – often referred to as “adherence”. Even when pregnant women receive adequate quantities of MMS,  the supplements are not always consumed as recommended. This can be referred to as the “adherence gap” – the gap between receipt and consumption of micronutrient supplements delivered through the ANC platform.

In Nigeria, the Federal Ministry of Health (FMoH) expressed interest in transitioning from

IFA supplementation to MMS and requested more implementation evidence in the Nigerian context to understand the realities of switching from IFA supplements to MMS and to explore how to increase pregnant women’s adherence to MMS. NI is working alongside the government of Nigeria to undertake the implementation research. 

Project Overview

This 3-year implementation research project, funded by the Bill and Melinda Gates Foundation, aims to design and test human-center designed (HCD) strategies that will optimize adherence (“adherence solutions”) to and uptake of MMS among pregnant women in Nigeria. It also provides an opportunity to increase attention to maternal nutrition, strengthen the ANC platform, and improve gender-based outcomes such as women’s decisionmaking ability.  

To measure the impact of the adherence solutions on pregnant women’s adherence to MMS and the impact of the IFA-MMS transition, an outcome evaluation, composed of a baseline and an endline survey, will be conducted. A process evaluation will also be conducted to help further refine, adapt, and support implementation and to help contextualize the results of the outcome evaluation and inform scale-up.

Project Activities

An overview of the project’s phases and activities is summarized in Annex A. Some of these phases and activities are described below: 

1. Project implementation: Small-scale MMS demonstration projects will be set up through the existing public ANC platform in selected Local Government Areas (LGAs) (i.e. Dass, Giade, and Ganjuwa) in Bauchi state to serve as a testing ground for the implementation research on adherence. MMS will be implemented in these LGAs, meaning that all pregnant women accessing public ANC services in these geographies will be provided with MMS instead of IFA supplements for the duration of their pregnancy, alongside a ‘standard introduction package’. This standard package will include standard operating procedures, MMS fact sheet, and monitoring forms for healthcare providers. NI is managing the procurement of UNIMAPP-compliant MMS and is working with the government and implementing partners to ensure there is sufficient MMS in the project sites. Ongoing monitoring and adaptive implementation will be an important component of this pillar. Regular meetings with pregnant women and their influencers will guide the roll out and complement the findings from the routine monitoring and supportive supervision of healthcare providers.
2. Implementation research: Implementation research is taking place in the selected LGAs in Bauchi State and is composed of three phases: (1) the preparatory phase, (2) the participatory design phase, and (3) the testing and evaluation phase. These three phases are summarized below:
   1. The preparatory phase: This phase was initiated in July 2022 and is expected to end in August 2023. It includes a landscape analysis and formative research.   

• The participatory design phase: This phase is expected to end in November 2023. During this phase, the indicative list of research questions will be distilled, drawing on findings from the preparatory phase and consultations with government and key stakeholders. A series of co-creation workshops will be used to consolidate this information and design a set of adherence solutions which will be implemented in the intervention arm sites.
  • This participatory process will rely on a diverse team including women and their influencers in addition to gender, nutrition,

programming, and HCD experts to bring together varying perspectives. 

1. An initial PIP will be created describing the implementation and intended impact of the adherence solutions and paving the way for operationalization. 

• The testing and evaluation phase: This phase is expected to begin in September 2023 (standard introduction) and January 2024 (adherence solutions) and end in March 2025. In this phase, a cluster randomized control design will be used to evaluate the effectiveness of the MMS adherence solutions (intervention arm) in terms of improving adherence, compared against the MMS standard introduction package (control arm), while taking into consideration the current IFA supplementation provided through the government system (reference arm). This phase will also look at implementation research outcomes such as acceptability, feasibility, sustainability, equity, and cost-effectiveness, as per WHO’s focus areas. The study sites will be determined and will be randomly assigned to one of following arms: 
  • Intervention Arm: Pregnant women in these study sites will receive MMS and the adherence solutions as part of their ANC.
  • Control Arm: Pregnant women in these study sites will receive MMS and the ‘standard introduction package’ as part of their ANC.    
  • Reference Arm: A third arm will be selected from a separate LGA where IFA is used as the standard of care and no MMS has been introduced. Pregnant women in the reference arm will continue to receive the existing government standard of care for ANC which includes only IFA (without any MMS).  This reference arm will serve to contextualize and better understand any differences in outcomes between the intervention and control arms. This reference arm is required because MMS is not currently part of the standard approaches used in the government system; hence, there is a lack of “usual care” with MMS to serve as a true counterfactual. The specifics of the research design will depend on the final research question and the adherence solutions being tested.

In this testing and evaluation phase, outcome and process of the adherence solutions will be evaluated. The outcome evaluation, which is the focus of this TOR, is further discussed in the sections that follow. The process evaluation (which is described in a separate RFP) will be conducted, with a HCD lens and guided by the PIP, to help further refine, adapt, and support implementation. In parallel, an ex-ante costing study with a cost-effectiveness analysis will provide an assessment of cost-benefits and inform the expected return on investment and scalability. The findings from this phase will be validated, analyzed, and synthesized to understand whether and how these solutions shifted adherence and provide recommendations for a path to scale.

Project timelines

This project started in July 2022 and is expected to end in June 2025. The baseline survey (field work and analysis) is expected to take place in December 2023, and the endline survey is expected to take place from January 2025 (field work and analysis) to March 2025.  

Rationale and Overall Aim of the Outcome Evaluation

This outcome evaluation’s overall aim is to assess the impact of the “adherence solutions” on pregnant women’s adherence to MMS through public routine ANC in Bauchi state. It will also generate adherence data which will be used as part of the cost-effectiveness evaluation.

Results from the outcome evaluation will serve to inform the FMoH on the feasibility of scaling-up MMS in Nigeria. 

Specific Activities of the Outcome Evaluation

This aim will be achieved by completing the following activities:

1. Finalize the design and the necessary planning and preparation for the outcome evaluation in line with requirements set out by NI:
   1. Prepare a research protocol including, but not limited to, a description of the evaluation design and methodology, sampling plan, data collection and analysis, workplan and budget.
   1. Develop, translate, and pilot test the baseline and endline survey evaluation tools (such as questionnaires and consent forms).
   1. Apply for and obtain permission from the National and Bauchi state recognized ethics review boards.
   1. Liaise with government through the TWG for selection of appropriate team for data collection and supervision. 
   1. Develop training for evaluation tools and train data collectors on proper administration. 

• Coordinate, supervise, and quality assure data collection for the outcome evaluation.
  • Plan and implement data collection for the outcome evaluation. 
  • Prepare and implement quality assurance and quality control mechanisms.

• Clean, analyse, interpret, report, and present the data. 
• Synthesize the main findings and produce a report that answers the research questions.
  • Produce survey reports and a final evaluation report.
  • Present the evaluation findings to NI staff. 

• Any other work as deemed necessary to complete the outcome evaluation.  

Key deliverables and tentative timelines

Required profile

The consultant(s)/agency interested in submitting a proposal to conduct this study should have: 

• At least 5 years of experience in conducting outcome evaluations and/ or process or impact evaluations in the field of public health nutrition and health promotion, ideally with emphasis on maternal health in Nigeria. Experience in Bauchi State would be an asset. 
• Familiarity with the context and health system in Bauchi State is desirable.
• The most up-to-date evidence on ANC recommendations and maternal and newborn health and nutrition programming and guidelines including maternal micronutrient supplementation in LMICs. 
• At least 5 years of experience in collecting and analyzing quantitative and qualitative data.  
• Access to a licensed copy of, and experience in using, quantitative software e.g. SPSS, Stata, SAS.  
• Completed a course on ethics in research on human participants and can train data collectors on protecting human participants in research before the data collection. 
• Include a qualified gender specialist as a member of, or contributor to the team to provide expertise specific to scope and context of the work. 
• Provide evidence of having undertaken similar or related research work previously
• Language skills: Speaking and writing in English and Hausa.

Submitting the proposal

Full proposals need to be submitted via email to the following address with all attachments in docx or PDF to [email protected] by the deadline of August 11^th, 2023. 

Please use subject line “Outcome evaluation partner for MMS Project in Bauchi, Nigeria”. For any clarification required, please email to [email protected] with the subject line “Clarification needed – Outcome evaluation partner for MMS in Bauchi, Nigeria”

The application must include:

A) Cover Letter: Proposals must be accompanied by a cover letter (not exceeding 1 page) with the respondent’s address. The letter must be signed by a suitable authority to commit the agency to a binding contract. It must quote the RFP number and title.B) Signed Declarations provided in Annex B of this document. 

• Detailed technical proposal: This should not exceed 7 pages. Proposals should serve as a technical response clearly outlining how the outcome evaluation would be implemented in Bauchi State. A list of acronyms used in the proposal must be included.
• Annexes to include in proposal:
  • Qualifications and experience:
    • Provide examples of previous related research, highlighting experience in supervision or contribution to similar studies.  
    • Include a sample of a previous report(s) or research that the team has produced (preferably outcome or impact evaluation report – up to 2 reports). 
    • Show qualifications of the key personnel of the team, including resumes/CVs of each of the key team members (up to 3 pages per CV). 
    • A description of the roles and responsibilities of each of the team members and expected LOE for each (up to 2 pages). 
    • When any sex and gender-based research and analysis is required, the proposal and subsequent research work should be reviewed by a qualified gender specialist(s).

• Timeline: A sample timeline template can be found in Annex C. The timeline for the outcome evaluation should include deadlines for each activity proposed.
  • Financial proposal (up to 3 pages) submitted in a separate file in Excel detailing:  
    • A budget based on the format attached as Annex D. 
    • Breakdown of all activities, outputs, and deliverables. 
    • Estimated cost disaggregated by the number of days each of the team members will be working.
    • Dates when separate financial reports will be submitted and when payment will be expected. 
    • All amounts need to be quoted in in Nigerian Naira and US Dollars. Fees should be inclusive of all insurance and standard business overheads and taxes.  
    • NI will not pay for any overhead or indirect costs that exceed 10% of the total direct costs to for-profit agencies. For NGOs or public institutions (governments or universities), NI can provide 10% for indirect/overhead cost on the total budget.

• Risk analysis exercise: The consultant(s)/agency shall identify barriers and risks of conducting the outcome evaluation and, for each risk, indicate what would be done to respond to these challenges.

Evaluation process

The following criteria will be adopted to short list the proposals and identify suitable agencies for contract award. Out of the total scores, 70% of weighting will be assigned to technical and 30% to the financial proposal. 

Annex A: Overview of project’s phases and activities 

Annex B: Declaration Form

We have examined the information provided in your Request for Proposals (RFP) and offer to undertake the work described in accordance with requirements as set out in the RFP.  This proposal is valid for acceptance for 6 months and we confirm that this proposal will remain binding upon us and may be accepted by you at any time before this expiry date.”   

“We accept that any contract that may result will comprise the contract documents issued with the RFP and be based upon the documents submitted as part of our proposal.   

“Our proposal (Technical and Financial) has been arrived at independently and without consultation, communication, agreement or understanding (for the purpose of restricting competition) with any other Respondent to or recipient of this RFP from the Nutrition International.  

“All statements and responses to this RFP are true and accurate.”  

“We understand the obligations regarding Disclosure as described in the RFP Guidelines and have included any necessary declarations.”  

“We confirm that all personnel named in the proposal will be available to undertake the services.”  

“We agree to bear all costs incurred by us in connection with the preparation and submission of this proposal and to bear any further pre-contract costs.  

“I confirm that I have the authority of [insert name of organization] to submit this proposal and to clarify any details on its behalf.”  

Name: ………………………………….  

Title: …………………………………….  

Date: ……………………………………  

Signature: ……………………………

Annex C: Project Implementation Plan, Timetable, and Roles and Responsibilities

Annex D: Budget Template

Nutrition International Nigeria Programs. Available at: https://www.nutritionintl.org/wpcontent/uploads/2019/11/Nigeria-Country-Brief.pdf

World Health Organization. (2016). WHO recommendations on antenatal care for a positive pregnancy experience. 

World Health Organization.

Interim Country-level decision-making guidance for introducing MMS for pregnant women. https://www.nyas.org/media/22939/111220-mms-guidance-v10.pdf

Federal Ministry of Health. (2021). National Guidelines for the prevention and control of micronutrient deficiencies in Nigeria. Federal Ministry of Health, Department of Family Health, Nutrition Division.