Common use of Challenges Clause in Contracts

Challenges. The primary challenges HBEPD has identified in successful, timely implementation of the FFE Partnership are ongoing challenges:  Arkansas’s Legislative process for obtaining approval to spend grant funds once awarded, create and fill staff positions, and secure consulting contracts is part tedious attention to detail and part political. With our recent experience, HBEPD is better prepared to meet the detailed, time-sensitive requirements. We are hopeful that the continuous openness we’ve shown to our legislators throughout our planning process coupled with the able support of the AID Commissioner and the Governor’s office will lead to approval of our requests the first time they are presented to Legislative committees.  Misinformation is being perpetuated by those opposed to ACA throughout Arkansas. Beginning with our recent Town Meetings and continuing with our soon to be implemented outreach and awareness efforts, HBEPD is making a concerted, organized effort to provide concise, accurate information to all Arkansans.  It takes time and valuable resources to bring new staff and/or consultants on board. Learning from our past experience, we are revamping our new employee orientation to deploy when new staff is hired. To minimize the learning curve for consultants, we plan to keep many of the same ones in place to continue the valuable work they are doing.  Arkansas is involved in multiple health system improvement efforts which all place demands on the same staff, agency, and other leaders at a time of limited resources. Interagency coordination and collaboration are intentional and funding through this cooperative agreement will assist in advancing the important work of Arkansas’s FFE Partnership implementation. There are a couple of challenges we have identified that are beyond our control to influence at this point:  There remain many unanswered questions and unissued guidelines from CCIIO/CMS regarding the implementation of the FFE Partnership Model. We will continue to ask for guidance and, when appropriate, suggest solutions for CCIIO/CMS to consider. Of particular concern the lack of information about long-term FFE Partnership fees and financing, the expectations for the federally managed Navigator Program as related to the state-managed IPA Program, and specific points of plan management such as processes and requirements for FFE approval of any state requested QHP criteria beyond federal minimum requirements.  In light of the recent Supreme Court decision, Arkansas has not decided what it plans to do about Medicaid expansion. This raises many questions about what will be available for this at-risk population between 17% and 100% of FPL if Arkansas does not expand its program. There are also questions about churning between the IAP programs and we plan to address churning and related issues through this Level One Funding.

Challenges. The primary challenges HBEPD AHCD has identified in successful, timely implementation of the FFE Partnership SPM are ongoing challengesongoing:  Arkansas’s Legislative process for obtaining approval to spend grant funds once awarded, create and fill staff positions, and secure consulting contracts is part tedious requires much attention to technical detail as well as an awareness and part politicalunderstanding of political situations as they evolve. With our recent experienceAs noted earlier, HBEPD is better prepared we did not receive legislative approval to meet spend the detailedLevel One B funds (awarded September 27, time-sensitive requirements2012) until December 21, 2012. Level One C funding, received April 7, 2013, was approved for spending May 28, 2013. We are hopeful that the continuous openness we’ve shown to our legislators throughout our planning process coupled with the able support of the AID Commissioner and the Governor’s office will lead to approval of our requests in a more timely manner. Also, the first time they are presented Legislature’s approval of the premium assistance Medicaid Expansion model may facilitate future appropriations of grants received for Marketplace operations. We must continue to Legislative committeesbe aware that many in the Legislature oppose any aspect of the ACA.  Misinformation is being perpetuated by those opposed to ACA throughout Arkansas. Beginning with our recent Town Meetings and continuing with our soon Preparing for open enrollment: Plans are expected to be implemented outreach certified by HHS in early September to be sold on the FFM in Arkansas, IPAs must be trained, hired, and awareness effortslicensed as must all categories of assisters, HBEPD and the Outreach and Education campaign funding for the open enrollment period must receive legislative approval to continue.  A lack of information and misinformation about the ACA is making widespread, not only in Arkansas, but nationwide. A major focus of our Outreach and Education campaign is a concerted, organized effort to provide concise, accurate information to all Arkansans.  It takes time and valuable resources to bring new staff and/or consultants on board. Learning from our past experience, we are revamping We have redesigned and expanded our new employee orientation to deploy when new staff is hiredorientation. To minimize the learning curve for consultants, we plan to keep many of the same ones in place to continue the valuable work they are doing.  Arkansas is involved in multiple health system improvement efforts which all place demands on the same staff, agency, and other leaders at a time of limited resources. Interagency coordination and collaboration are intentional and funding through this cooperative agreement will assist in advancing the important work of Arkansas’s FFE Partnership SPM implementation. There are  As a couple state with the third-lowest per capita income, we projected a high percentage of challenges churning between insurance affordability programs and have contracted with Manatt Health Solutions to help design and implement an effective state-specific strategy to decrease churning and promote continuity of care. Xxxxxx’x help was critical in promoting the premium assistance Medicaid Expansion model. However, we have identified that are beyond our control still await final approval from HHS for the Private Option. Then, the challenge will be to influence at this point: make it function smoothly and effectively. Many pieces must come together. But with proper planning, expertise, and hard work, we’re confident of success.  There remain many unanswered questions and unissued guidelines from CCIIO/CMS regarding the implementation of the FFE Partnership ModelHHS. We will continue to ask for guidance and, when appropriate, suggest solutions for CCIIO/CMS to considerconsider as issues arise. Of particular concern We appreciate the lack of information about long-term FFE Partnership fees and financing, thoughtful assistance from CCIIO at a time when the expectations for federal government is trying to coordinate with all 50 states to get the federally managed Navigator Program as related to the state-managed IPA Program, and specific points of plan management such as processes and requirements for FFE approval of any state requested QHP criteria beyond federal minimum requirements.  In light of the recent Supreme Court decision, Arkansas has not decided what it plans to do about Medicaid expansion. This raises many questions about what will be available for this at-risk population between 17% and 100% of FPL if Arkansas does not expand its program. There are also questions about churning between the IAP programs and we plan to address churning and related issues through this Level One FundingMarketplace projects in place.

Challenges. The primary challenges HBEPD has identified in successful, timely implementation of the FFE State Partnership Exchange are ongoing challenges:  • Arkansas’s Legislative process for obtaining approval to spend grant funds once awarded, create and fill staff positions, and secure consulting contracts is part tedious attention to detail and part political. With our recent experienceAs noted earlier, HBEPD is better prepared we did not receive Legislative approval to meet spend the detailedLevel One B funds (awarded September 27, time-sensitive requirements2012) until December 21, 2012. We are hopeful that the continuous openness we’ve shown to our legislators throughout our planning process coupled with the able support of the AID Commissioner and the Governor’s office will lead to approval of our requests in a more timely manner. However, the Arkansas General Assembly that just took office is controlled in both xxxxxxxx by the Republican Party for the first time they since Reconstruction which could actually increase this challenge going forward as many of those legislators are presented to Legislative committeesnot supporters of ACA or the Health Insurance Marketplace.  • Misinformation is being perpetuated throughout Arkansas by those opposed to ACA throughout ArkansasACA. Beginning with A major focus of Phase 1 of our recent Town Meetings Outreach and continuing with our soon to be implemented outreach and awareness efforts, HBEPD Education campaign is making a concerted, organized effort to provide concise, accurate information to all Arkansans.  • It takes time and valuable resources to bring new staff and/or consultants on board. Learning from our past experience, we are revamping We have redesigned and expanded our new employee orientation to deploy when new staff is hired. To minimize the learning curve for consultants, we plan to keep many of the same ones in place to continue the valuable work they are doing.  • Arkansas is involved in multiple health system improvement efforts which all place demands on the same staff, agency, and other leaders at a time of limited resources. Interagency coordination and collaboration are intentional and funding through this cooperative agreement will assist in advancing the important work of Arkansas’s FFE State Partnership Exchange implementation. There are • As a couple state with the third lowest per capita income, we expect a high percentage of challenges we churning between insurance affordability programs and have identified that are beyond our control contracted with Manatt Health Solutions to influence at this point:  help design and implement an effective state-specific strategy to decrease churning and promote continuity of care. • There remain many unanswered questions and unissued guidelines from CCIIO/CMS regarding necessary for effective coordination and monitoring between the implementation of the FFE Partnership Modelfederal Navigator and state IPA programs. We will continue to ask for guidance and, when appropriate, suggest solutions for CCIIO/CMS to consider. Of particular concern the lack of information about long-term FFE Partnership fees and financing, the expectations for the federally managed Navigator Program as related to the state-managed IPA Program, and specific points of plan management such as processes and requirements for FFE approval of any state requested QHP criteria beyond federal minimum requirements.  In light of the recent Supreme Court decision, • Arkansas still has not decided what it plans to do about Medicaid expansion. This raises many questions about what will be available for this at-risk population between 17% and 100% of FPL if Arkansas does not expand its program. There are also questions about churning between the IAP programs and we plan to address churning and related issues through this Level One Funding.

Challenges. The primary challenges HBEPD has identified in successful, timely implementation of the FFE Partnership are ongoing challenges:  • Arkansas’s Legislative process for obtaining approval to spend grant funds once awarded, create and fill staff positions, and secure consulting contracts is part tedious attention to detail and part political. With our recent experience, HBEPD is better prepared to meet the detailed, time-sensitive requirements. We are hopeful that the continuous openness we’ve shown to our legislators throughout our planning process coupled with the able support of the AID Commissioner and the Governor’s office will lead to approval of our requests the first time they are presented to Legislative committees.  • Misinformation is being perpetuated by those opposed to ACA throughout Arkansas. Beginning with our recent Town Meetings and continuing with our soon to be implemented outreach and awareness efforts, HBEPD is making a concerted, organized effort to provide concise, accurate information to all Arkansans.  • It takes time and valuable resources to bring new staff and/or consultants on board. Learning from our past experience, we are revamping our new employee orientation to deploy when new staff is hired. To minimize the learning curve for consultants, we plan to keep many of the same ones in place to continue the valuable work they are doing.  • Arkansas is involved in multiple health system improvement efforts which all place demands on the same staff, agency, and other leaders at a time of limited resources. Interagency coordination and collaboration are intentional and funding through this cooperative agreement will assist in advancing the important work of Arkansas’s FFE Partnership implementation. There are a couple of challenges we have identified that are beyond our control to influence at this point:  • There remain many unanswered questions and unissued guidelines from CCIIO/CMS regarding the implementation of the FFE Partnership Model. We will continue to ask for guidance and, when appropriate, suggest solutions for CCIIO/CMS to consider. Of particular concern the lack of information about long-term FFE Partnership fees and financing, the expectations for the federally managed Navigator Program as related to the state-managed IPA Program, and specific points of plan management such as processes and requirements for FFE approval of any state requested QHP criteria beyond federal minimum requirements.  • In light of the recent Supreme Court decision, Arkansas has not decided what it plans to do about Medicaid expansion. This raises many questions about what will be available for this at-risk population between 17% and 100% of FPL if Arkansas does not expand its program. There are also questions about churning between the IAP programs and we plan to address churning and related issues through this Level One Funding.

Challenges. Challenges encountered during the reporting period are summarized below. Overall, the project’s full-scale implementation is proceeding well, and many activities are ahead of schedule. However, a few challenges have been noted, these are: ▪ The primary lack of project vehicles for activity implementation, especially travel for community activities in difficult to reach locations has been a challenge that our teams have had to overcome, which has drawn out community-level engagement planning processes. ASBC continues to expend resources on car rentals and leases but remains hopeful that vehicle approval will come soon, ▪ Lack of accurate data on the cadre of health promotion staff currently at post nationwide (regional, district, sub-district, facility, and community level) has hindered planning. ▪ The need to meeting multiple and growing demands (e.g., emerging infectious diseases, vaccine hesitancy, new program development, and project start-up) of a new and vibrant Division (HPD) whilst managing an ongoing change process to become the SBC thought leader within GHS has place strain on existing ASBC staff. But improvement in the division of labor and the “teaming” of HPD and ASBC staff has improved the work flow and increased collaboration. ▪ Blending varying work cultures, procedures, and processes while ensuring project deadlines and deliverables are met. HPD’s work culture and institutions are different from the pace of work and deadline-based accountability familiar to most NGOs and private sector entities. Aligning these cultures and work styles is an on-going process. ▪ Coordination between ASBC, consortium partners, and HPD at national and sub-national levels to synchronize calendars, often lead to delayed activity implementation. A large and complex project that is spread geographically across Ghana has led to numerous communication and coordination challenges HBEPD that can be expected of a new project. Efforts are continuing to improve communication channels and streamline work flows are underway and it is expected that as program activities continue to roll out and de- centralization of decision making continues. Lessons Learned “Prior to joining the team, I was not motivated coming to the office, but now I have a lot to do. I am always motivated coming to work now; this makes me happy.” HPD Staff and a member of the joint capacity strengthening team, April 2022. Success is achieved through collaborative work. Following the successful relocation of ASBC staff within GHS HPD Head Office (and Tamale), , the Director of the Division together with the Acting Chief of Party, , constituted teams to work on the three main components of the project-Capacity Strengthening and Partnership Engagement, Community Engagement, Monitoring and Evaluation. Each team consists of a maximum of six members made of HPD staff and ASBC Advisors/Specialists that are responsible for specific project components. Each team meets weekly to plan and jointly implement field activities. This approach to work is helping with cross fertilization of ideas, knowledge transfer, trust building, sense of urgency and a more structured approach to work. The Director of HPD has identified developed a monthly performance tracking tool that is used to track progress of work. At the Division’s bi-weekly meetings HPD/ASBC staff provide updates on progress from their respective units. HPD staff have so far played lead roles in successfulthe review and implementation of community engagement activities together with ASBC consortium partners. Furthermore, timely they have participated in SBC capacity assessments, worked with external consultants to undertake the comprehensive capacity review of the Division, and participated in key stakeholders’ meetings. This collaborative work has ignited a sense of ownership of the project by HPD leadership, and they are now chief advocates for the project within GHS. Additionally, ASBC has taken a deliberate approach to engagement that emphasizes HPD primacy and leadership in all program activities and planning. HPD leads all implementation with ASBC taking a secondary role in the decision-making and planning process. Most impactful procurement and contracts are subject HPD approval and FHI360 (as prime) has been deliberately transparent with respect to plans, budgets and strategies to ensure that HPD is not just a recipient of technical and financial support but an equal co-implementor of the ASBC project. There is a significant mindset shift with respect to program implementation that is underway, where HPD leadership directs workflow allocation, teaming, and resource allocation which has resulted in the establishment of trust and transparency between HPD and ASBC teams. This is an important lesson that has contributed to the successful start-up and implementation of the FFE Partnership are ongoing challengesactivity to date. Success Stories Success Story 1:  ArkansasGhana’s Legislative process First Ever Social and Behavior Change Summit Contributing to implementing the United States Agency for obtaining approval to spend grant funds once awardedInternational Development (USAID)/Ghana Country Development Cooperation Strategy (CDCS), create 2020-2025, which emphasizes changing behaviors across sectors for significant impact and fill staff positionssustained results, the Ghana Health Service Health Promotion Division (GHS-HPD), United Nations Children’s Fund (UNICEF), and the USAID/Ghana Accelerating Social and Behavior Change (ASBC) Activity collaboratively organized the first-ever Social and Behavior Change (SBC) Evidence Summit in Ghana. The summit key outcome was to develop a fully aligned research agenda across partners that fill critical evidence gaps to drive evidence-based programming in the USAID Zone of Influence (ZOI) and Ghana in general. During the summit, stakeholders examined the current state of behavioral evidence in the ZOIs in family planning, reproductive health, malaria, nutrition, maternal and child health, and COVID-19 from published literature spanning the Group picture of SBC participants Group session validating evidence gaps and formulating a research agenda period 2016 to early 2022. The two-day hybrid (both in-person and virtual) SBC Evidence Summit took place on August 1st and 2nd 2022 in Accra and brought together 123 representatives from GHS-HPD, UNICEF, USAID implementing partners in the ZOIs, partner non-governmental organization (NGOs), and donor institutions. Approaches used for the summit included a review and validation of published literature (behavioral evidence in health areas were compiled, printed, packaged, and distributed to participants), presentations, group sessions, and plenary discussions. Presentations were also made by partners, including Total Family Health Organization (TFHO), UNICEF, Catholic Relief Services (CRS), Xxxxxxx and Xxxxxxx (J&J), Xxxx Xxxx, Inc. (JSI), HPD, Savana Signatures, Rural Initiatives for Self Empowerment (RISE) Ghana, Norsaac, and Global Communities on SBC-related research findings and projects. The summit was a success, and this was corroborated by overwhelming and positive feedback from participants. They described the summit as packed, informative, and engaging. Word cloud of how participants felt at end of Day 1 A sample of participants quotes are presented below: • “The idea of reviewing literature to identify what is known to come up with gaps was so fascinating to me.” • “I loved the group work and the contributions that were shared.” • “Presentations from different partners on their research on SBC provided the platform to ensure synergy in upcoming research.” The GHS-HPD’s key role in public health delivery and organizing the SBC Evidence Summit demonstrates its readiness to lead, support, and coordinate SBC interventions and research in Ghana. A research sub-committee of the Inter-agency Coordinating Committee for Health Promotion (ICC-HP) was proposed to coordinate and spearhead follow-up actions from the inaugural Evidence Summit such as the coordination of a uniform research agenda to address known behavioral gaps in the literature and better coordinate future formative and evaluative research. Success Story 2: Achieving Results through Effective GHS Leadership and Stakeholder Engagements Two tailor made capacity strengthening activities, the Change Agents Development Program (CADP), and the Set for Change (SfC) action learning sets, were introduced under C4H to enhance Social and Behavior Change (SBC) competencies of health promotion staff. As competitive training opportunities, health promotion staff are required to send in applications to be screened. Calls for applications yielded minimal responses. Multiple calls for applications and extension of deadlines were utilized to secure consulting contracts required participants. Under Accelerating Social and Behavior Change (ASBC) Activity the joint HPD/ASBC team, learning from the past; purposely engaged the top leadership of Ghana Health Service (GHS) and their Human Resource Division (HRD) in planning the program rollout. The call for applications received a massive response from across the country. The overwhelming response has been attributed to the support received from the Director General of GHS and the Director for HPD in championing these opportunities for health promotion staff. They created awareness about the activities within the senior leadership group of GHS, which aided Regional Health Directors to communicate the benefits of the training activities to their staff. Further, the renewed involvement of the GHS HRD in HPD/ASBC activities, such as the review of the CADP and SfC curriculum has effectively anchored HPD/ASBC capacity strengthening within appropriate GHS structures. Additionally, the joint HPD/ASBC Capacity Strengthening team provided timely responses to inquiries by applicants via calls, WhatsApp, and emails. It is part tedious attention worth mentioning that the Health Promotion Association of Ghana also supported the process by using its platform to detail and part politicaladvance the call for applicants, encouraging qualified members to apply. The three calls for applications under C4H spanning a period of over 24 months yielded a total of 142 applicants whilst the first call for applications under ASBC over a period of three months yielded 122 applicants. With our recent experience, HBEPD this number HPD/ASBC is better prepared positioned to meet run two cohorts of CADP and SfC with just one call of applications. The table below shows the detailed, time-sensitive requirements. We are hopeful that the continuous openness we’ve shown to our legislators throughout our planning process coupled with the able support of the AID Commissioner call for applications under C4H and the Governor’s office will lead to approval of our requests the first time they are presented to Legislative committeesresponses so far under ASBC.  Misinformation is being perpetuated by those opposed to ACA throughout Arkansas. Beginning with our recent Town Meetings and continuing with our soon to be implemented outreach and awareness efforts, HBEPD is making a concerted, organized effort to provide concise, accurate information to all Arkansans.  It takes time and valuable resources to bring new staff and/or consultants on board. Learning from our past experience, we are revamping our new employee orientation to deploy when new staff is hired. To minimize the learning curve Communicate for consultants, we plan to keep many of the same ones in place to continue the valuable work they are doing.  Arkansas is involved in multiple health system improvement efforts which all place demands on the same staff, agency, and other leaders at a time of limited resources. Interagency coordination and collaboration are intentional and funding through this cooperative agreement will assist in advancing the important work of Arkansas’s FFE Partnership implementation. There are a couple of challenges we have identified that are beyond our control to influence at this pointHealth Accelerating Social Behavior Change Activity Cohort CAPD SfC Total Cohort CADP SfC Total 2nd 20 31 51 3rd 45 27 72 Xxxxx X:  There remain many unanswered questions and unissued guidelines from CCIIOASBC Performance Plan Reporting (PPR) Indicators Indicator Jan- Mar Apr - Jun Jul - Sept Year 1 Achievements Year 1 Target Comments/CMS regarding the implementation of the FFE Partnership Model. We will continue to ask for guidance and, when appropriate, suggest solutions for CCIIO/CMS to consider. Of particular concern the lack of information about long-term FFE Partnership fees and financing, the expectations for the federally managed Navigator Program as related to the state-managed IPA Program, and specific points of plan management such as processes and requirements for FFE approval of any state requested QHP criteria beyond federal minimum requirements.  In light of the recent Supreme Court decision, Arkansas has not decided what it plans to do about Medicaid expansion. This raises many questions about what will be available for this at-risk population between 17% and 100% of FPL if Arkansas does not expand its program. There are also questions about churning between the IAP programs and we plan to address churning and related issues through this Level One Funding.Remarks