RFI_TB_Private_Sector.pdf

REQUEST FOR INFORMATION

USAID/Indonesia Tuberculosis Private Sector Activity

Subject: Request for Information (RFI)

Date of issuance: February 14, 2018

Response due: March 1, 2018 (2:00 p.m., Jakarta time)

Response to: proposals-indo@usaid.gov

This is a Request for Information (RFI) only as defined in FAR 15.201(e), to obtain information related to interest, capabilities, and market information from potential offerors. This RFI relates to an activity with the preliminary title of “Tuberculosis Private Sector Activity”.

The purposes of this RFI are to:

1. Obtain details concerning interest in USAID’s anticipated requirements described herein;

2. Obtain information on the level of capacity of potential offerors relevant to the draft

Statement of Work (SOW); and

3. Solicit and obtain input and feedback on the draft SOW, instruction to the offerors, and evaluation factors.

Please do not submit any proposals at this time; only information requested in this RFI will be reviewed. Responses will be treated as confidential. This is not a Request for Proposals (RFP) and is not to be construed as a commitment by the U.S Government to issue any solicitation or ultimately award a contract on the basis of this RFI, or to pay for any cost incurred in the preparation and submission of comments on this RFI. If a solicitation is released it will be posted in www.fbo.gov. It is the potential offeror’s responsibility to monitor this site for the release of any synopsis or solicitation. It should be noted that responding to this RFI will not give any advantage to any firm or organization in the subsequent procurement.

All responses must be sent using the cover page as Attachment No. 3 to this RFI. All responses must be submitted electronically via email to proposals-indo@usaid.gov with the subject title “RFI: Tuberculosis Private Sector Activity” no later than the date/time stated above.

Respondents will only receive an electronic confirmation acknowledging receipt of your response, but will not receive individualized feedback on any suggestions.

USAID values concise, issue-specific responses. Responses should be no more than 4 (four) pages in length (not including the cover page of Response Form). Responses to the RFI must http://www.fbo.gov/ http://www.fbo.gov/ http://www.fbo.gov/ http://www.fbo.gov/ http://www.fbo.gov/ http://www.fbo.gov/ mailto:proposals-indo@usaid.gov be written in English, shall use only 8 ½” x 11” paper, single spaced, 11pt font. Number each page consecutively.

Please ensure submitted comments make specific reference to page and section numbers.

Respondents may also include self/organization information, including past experiences working in this subject area, experience working with other stakeholders, including implementing partners on the ground or host country government officials, or capacity information. Any information submitted in response to this RFI is voluntary. Not responding to this request does not preclude participation in any future solicitation, if any is issued.

Standard Clause: FAR 52.215-3 Request for Information or Solicitation for Planning Purposes (OCT 1997)

(a) The Government does not intend to award a contract on the basis of this solicitation or to otherwise pay for the information solicited except as an allowable cost under other contracts as provided in subsection 31.205-18 Bid and Proposal Costs, of the Federal Acquisition Regulation.

(b) Although “proposal” and “offeror” are used in this Request for Information, your response will be treated as information only. It shall not be used as a proposal.

(c) This solicitation is issued for the purpose of obtaining information about the interests, capabilities, reasonable prices, and market information related to the enclosed draft statement of work.

Thank you for your assistance and interest in USAID/Indonesia’s programs.

Sincerely, /s/ Albert Carrera Contracting Officer USAID/Indonesia

Attachment:

1. RFI Questions

2. Draft Section C - Statement of Work, Section L - Instructions to Offeror and Section

M - Evaluation Factors for Award

3. Cover Page Response Form (MS Word document)

Attachment 1

USAID/INDONESIA

TUBERCULOSIS PRIVATE SECTOR ACTIVITY

REQUEST FOR INFORMATION (RFI)

No. AID-497-RFI-18-000004

PURPOSE OF THE RFI

Noting the practical issues of designing and implementing a tuberculosis activity centered around engaging a wide array of stakeholders, USAID/Indonesia is soliciting comments from individuals, companies, and organizations with regard to the activity statement of work (SOW), evaluation factors and instructions to the Offeror. It is reminded that the section C, L, and M in the attachment of the RFI is only a draft.

USAID/Indonesia welcomes input and comments in response to any or all of the following questions in order to ensure the activity encompasses a suitable suite of service capacities. Please ensure comments are concise and specific to information included within the activity SOW.

Questions to Consider for All respondents:

General:

● Do you have any general feedback on the SOW?

● What is unclear in the SOW?

● What is unclear in the evaluation factor?

● What is unclear in the instructions to the Offeror?

Technical:

● What alternative or additional approaches and related technical areas might be considered in order to accomplish the same three objectives as defined in the SOW? Please consider examples from other countries.

● To ensure proof of concept, without creating project dependency, i.e., using a systems approach, do you think the currently defined geographical scope is appropriate? If yes -why and if no - why not?

Respondents are free to address any or all of the above items, as well as provide additional information that they think is relevant to the SOW.

Attachment 2

USAID/INDONESIA

TUBERCULOSIS PRIVATE SECTOR ACTIVITY

ESTIMATED BUDGET: $17 - $20 million

IMPLEMENTATION PERIOD: FIVE YEARS

- DRAFT-

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

C.1 PURPOSE

The purpose of the Tuberculosis Private Sector (TBPS) Activity is to contribute to national goals to reduce tuberculosis (TB) prevalence and incidence by increasing the number of private provider clients who receive quality TB services.

C.2 BACKGROUND

a. Indonesia has the second largest TB burden in the world1

TB is the greatest killer worldwide due to a single infectious agent. Indonesia has the second largest TB burden in the world, with an estimated 1.6 million prevalent cases and 1 million incident cases per year (including an estimated 32,000 multidrug-resistant TB (MDR-TB) cases per year). In 2016, 358,608 new and relapse TB patients were notified in Indonesia, and the most recent cohort of notified patients had a treatment success rate of 85%. However, this means that only 35% of the estimated total of TB patients in the country are identified and notified. An inventory study2 that is currently underway in Indonesia will provide additional information on treatment location and gaps in notification.

b. TB patient volumes in the private sector are high and practices not optimal

Volume: The 2013-14 Indonesia TB prevalence survey indicated that 60% of clients with TB symptoms sought their initial care in the private sector; a recent patient pathway analysis used this and other data sources to estimate an even higher figure of 74% initial care seeking in the private sector.3 In terms of their eventual treatment location, the prevalence survey found that 42% of TB treatment (vs 9% of TB notifications) ended up taking place in the private sector, consistent with a survey of TB drug sales in 2009 that showed a large volume of TB drugs in the private sector.4

Case Notification: Given the public health mandate of the National Tuberculosis Program (NTP), private providers have not historically been a focus of TB interventions. This is reflected in the very low rates of case notification from the private sector, with only 9% of TB cases reported to the NTP originating with private providers. There is a steep drop-off from private care-seeking (60-74%) to private TB treatment (42%) to private TB notification (9%), indicating a multitude of lost opportunities to identify and notify TB patients in the private sector.

1 WHO TB report 2017. http://who.int/tb/publications/global_report/en/ 2 http://www.who.int/tb/publications/inventory_studies/en/ 3 Surya et al. Quality Tuberculosis Care in Indonesia: Using Patient Pathway Analysis to Optimize Public-Private Collaboration. J Infect Dis. 2017 Nov 6;216(suppl_7):S724-S732. doi: 10.1093/infdis/jix379.

4 Wells WA, Ge CF, Patel N, Oh T, Gardiner E, Kimerling ME. Size and usage patterns of private TB drug markets in the high burden countries. PLoS One. 2011 May 4;6(5):e18964. doi: 10.1371/journal.pone.0018964.

TB notification is not an end in itself, but forms the basis for monitoring and improving the quality of treatment. A number of studies in Indonesia have investigated care-seeking behaviors of TB symptomatic and resulting private provider actions. Consistent with international evidence, a number of these studies indicate substantial gaps in current private provider practice.5

C.3 CONTEXT FOR TBPS ACTIVITIES IN INDONESIA

The relevant context for the TBPS activity in Indonesia includes the three topics outlined below: overall political structure and governance; national approaches to TB private provider engagement; and the health financing landscape. All three topics are critical since the TBPS activity will be integrated with these national structures and strategies.

a. Political Structure and Governance

Indonesia is a diverse and highly decentralized middle-income country. There are multiple government actors who impact the issues considered here, including:

● Ministry of Health (MOH) / National TB Program (NTP), who sets standards for the TB response across the country and reports to the Director General of the Center for Disease Control (Direktur Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan, Kementerian Kesehatan, Ditjen

PPPL).

● National Health Insurance Agency (Badan Penyelenggara Jaminan Sosial-Kesehatan, BPJS-K), who acts as the single payer health insurance agency under the Government of Indonesia’s (GOI) Universal Health Insurance Program (Jaminan Kesehatan Nasional, JKN).

● MOH / Center for Financing and Risk Protection (Pusat Pembiayaan dan Jaminan Kesehatan, PPJK), who develops policies with regard to health expenditure tracking, private sector engagement and health financing related to the national health insurance program.

● National Development Planning Body (BAPPENAS), who is in charge of developing the National Mid Term Development Plan (RPJMN) by connecting different ministries to achieve common development goals.

● Provincial Health Offices, located in each Province, are responsible for budgeting, planning and implementing health services delivery at the provincial level, as well as providing oversight and guidance to the District Health Offices.

● District Health Office, located in the District, is responsible for budgeting, planning and implementing health services delivery at the district level.

● Professional Associations are responsible for engaging and setting norms for their membership.

Some of the key institutions include associations for pulmonologists (Perhimpunan Dokter Paru Indonesia - PDPI), medical doctors (Ikatan Dokter Indonesia - IDI), internists (Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia - PAPDI), pediatricians (Ikatan Dokter Anak Indonesia - IDAI), pharmacists (Ikatan Apoteker Indonesia - IAI), laboratory technicians (Ikatan

5 For example, see: Mahendradhata Y, et al. How do private general practitioners manage tuberculosis cases? A survey in eight cities in Indonesia. BMC Res Notes. 2015 Oct 14;8:564. doi: 10.1186/s13104-015-1560-7, and related articles from this and other research groups in Indonesia.

Laboratorium Kesehatan Indonesia - ILKI), hospitals (Perhimpunan Rumah Sakit Seluruh Indonesia - PERSI), medical clinics (Asosiasi Klinik Indonesia - ASKLIN) and private hospitals (Asosiasi Rumah Sakit Swasta Indonesia).

b. National Approaches to Engaging Private Providers in TB

Engaging with private providers for TB care is essential so that resources can be directed where they are needed, and so that quality of care can be improved to prevent the development of MDR-TB. The international effort on this front has been termed public-private mix (PPM). The outcomes of private provider engagement for TB in Indonesia were reviewed in depth during the Joint External Monitoring Mission (JEMM)6 in January 2017.

The importance of engaging private providers in Indonesia has been recognized in national TB plans since at least 2006. For the 2016-2020 National Strategic Plan (NSP), “improvement of networking TB services through public-private mix” is one of the main activities under Strategy 2: improving the quality of “TOSS-TB” (Temukan Obati Tuberkulosis Sampai Sembuh - Find and Treat TB until Recovered) services. Planned activities include developing technical guidance for district-based PPM, mapping service providers, signing MOUs and working with professional societies. Indicator 2.1 is “% of districts/municipalities with at least 80% of health services involved in PPM”, which is supposed to increase from 10% in 2016 to 90% in 2020, but this indicator focuses on coverage not programmatic achievement. The NSP includes estimates of funding requirements for each of six major NSP strategies, but there is no indication of any budget specifically for engaging private providers.

The NSP 2015-2019 estimates that only 2% of the private sector service providers are presently engaging with the NTP and only a very limited number of private providers are following national clinical standards and guidelines for TB care. Efforts to engage private providers have focused to-date on specialists and hospitals, where the numbers of patients per provider or facility tend to be higher than at the primary care level. The Pulmonologist Society, PDPI, has been working with the NTP since 2010 to improve involvement of pulmonologists and to increase adherence to treatment standards [the International Standards of TB Care (ISTC), or its Indonesian equivalent the Pedoman Nasional Pelayanan Kedokteran Tuberkulosis (PNPK)], in partnership with the American Thoracic Society and with funding from USAID and the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM). This has been a high yield intervention, but thus far has typically stopped with the specialists, rather than using the specialists to reach large numbers of GPs. In addition, efforts with both specialists and hospitals were reliant on donor funding, and ceased when donor support finished.

By contrast, there have been very few efforts to engage private providers at the primary care level. A $1 million TB REACH/Unitaid project, implemented by REMDEC in DKI Jakarta from 2013 to 2016, intended to engage private GPs and introduce GeneXpert, but could not be implemented as planned and had challenges with high pretreatment loss to follow-up. Since 2014, there has been an initiative to certify GPs for TB. However, the lengthy trainings, complex approval process, and multiple other ways to earn continuing medical education (CME) points resulted in only 35 GPs being certified.

6 MoH. (2017) The Joint External TB Monitoring Mission (JEMM TB) Indonesia http://www.searo.who.int/indonesia/topics/tb/tuberculosis_jemm_2017_for_ino_website.pdf?ua=1

Mandatory notification has been included in a final draft Decree of the Minister of Health related to TB Control stating that TB is a notifiable disease and that all health providers delivering TB services are obliged to report cases to the NTP. However, to be effective such a decree requires a simplified system for notification; WIFI-TB (see below) is an attempt to introduce such a system.

Based in part on the lessons learned from USAID-funded PPM programming (see Section C.5.a), the NTP has recently developed and embraced the district PPM model. In this model, a district-based team including health and governance authorities, medical associations, and other relevant institutions oversees overall PPM programming. Importantly, under this model, outreach to and engagement of individual practitioners and group clinics is devolved to the sub-district level, using puskesmas (primary health care center) staff, whereas outreach to hospitals is the direct responsibility of district-based staff. Under this approach, the NTP makes program drugs available to private providers. This model is currently being rolled out with the assistance of Challenge TB (see below), and should form the foundation for private provider approaches in TB PS.

c. JKN and the Role of BPJS-K for TB

The recent expansion of national health insurance in Indonesia brings increased opportunities to influence provider behaviors via financial levers. JKN currently provides health insurance coverage to over 180 million people, or almost 70% of the population, of whom over 92 million have subsidized premium payments from the government. The government aims to cover all its expected 275 million citizens by 2019.

Currently, only approximately 17 percent of the country’s total health expenditure, and approximately 30 percent of government spending on health, flows through the JKN system. However, as more people are enrolled and start to utilize care under the JKN program, expenditures through JKN are expected to increase. Already, greater than 780 public hospitals, 1190 private hospitals, and 9180 clinics are contracted by BPJS-K.7 Indonesia’s single-payer system has unleashed the power of strategic purchasing and has significant potential to dramatically increase efficiencies in resource allocation and increase access and financial protection for the poorest and most vulnerable.

However, under the current provider payment system (capitation at primary care and Indonesia-Case Based Groups at secondary care), JKN does not encourage optimal TB case finding or efficient case management at the primary or secondary care level.8 Currently, primary care capitation payments do not include TB-related performance incentives or specific payments for required diagnostics and pharmaceuticals, outside of what is included in the capitation payment. As a result, it seems that covering TB through the current capitation payment system is creating an incentive for primary health care (PHC) providers to refer TB cases to secondary and tertiary hospitals, and to avoid case-finding. For those who do treat clients at the primary care level, there is very little incentive to actively follow them through treatment completion. The lack of clarity over optimal patient pathways, and the absence of incentives that align with those optimal pathways, results in patient and provider confusion, increased out-of-pocket

7 See https://faskes.bpjs-kesehatan.go.id/aplicares/#/app/peta for numbers and distribution of BPJS-K providers.

8 See JEMM and BCG reports in Annex A.

https://faskes.bpjs-kesehatan.go.id/aplicares/#/app/peta costs, and excessive use of secondary care for TB symptomatics and patients. In addition, opportunities to screen outpatient clients for TB symptoms are also lost, because this is not a compensated activity under

BPJS-K.

There are ongoing efforts to further understand and pursue these issues by the GOI and other donors such as the World Bank and GFATM. Many of these efforts, whether they include TB explicitly or not, will provide data inputs for more evidence-based planning for TB interventions. For example, amongst other financing activities by GOI, the MOH-PPJK is producing unit cost data for JKN and non-JKN hospitals to get better cost of care data to inform INA-CBG provider tariff adjustments. In addition, BPJS-K is modifying capitation at PHC (based on, for example, contact rate, prevention activities, human resources for health, etc.). The World Bank activities include a Quantitative Service Delivery Survey with a sub-module for TB services in both public and private sectors; a Public Expenditure Tracking Survey that includes information on TB program specific financing and a recently completed Health Financing Sector Assessment (published in 2016).9

C.4 CURRENT USAID STRATEGIC FRAMEWORK

This TBPS activity is aligned with USAID/Indonesia’s Country Development Cooperation Strategy (CDCS). The current CDCS seeks to reorient USAID’s strategic engagement in Indonesia and provides an opportunity to address extreme poverty. USAID/Indonesia’s CDCS 2014–2019 has three integrated Development Objectives (DOs):

● DO 1: Democratic governance and security strengthened;

● DO 2: Essential human services to targeted populations improved and sustained; and

● DO 3: Development priorities for mutual prosperity advanced.

The TBPS Activity falls under the Infectious Disease Project, which implements intermediate result (IR)

3.1 Infectious disease threats reduced, under DO3.

USAID’s partnership with the GOI in infectious diseases reflects Indonesia’s commitment to improving and protecting the health of Indonesians, the region and the world. The TBPS activity intends to build on Indonesia’s significant achievements in health and the country’s aspiration to be a leader in the region. It also focuses on engaging and expanding Indonesia’s commitment and adherence to international standards of care and disease control, and strengthen its capacity for prevention, surveillance, and treatment of infectious diseases.

C.5 PAST AND CURRENT USAID ACTIVITIES RELATED TO TBPS

A number of past and current USAID activities are related to the TBPS activity, and provide a foundation for TBPS efforts. These include USAID support focused on general TB technical assistance, TB private care analysis, specialized topics in TB, and social health insurance in general, as outlined below.

9 World Bank, 2016. Indonesia Health Financing System Assessment.

http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17- LowRes.pdf

a. General TB technical assistance

Historically, USAID efforts in engaging the private sector to improve TB case notification and treatment success rates in Indonesia have been limited. However, recently, USAID has invested some resources in addressing private sector engagement in a scalable and sustainable manner, i.e., by integrating evidence-based approaches into the underlying health system.

TB CARE (2008-2013) implemented the following private sector activities in Indonesia: 1) initiated a Hospital DOTS Linkage Model, which struggled to maintain quality or to reach scale and was based on retaining patients under hospital care; 2) engaged specialists via the pulmonologists’ professional association (PDPI); 3) utilized one to three Wasors (GOI TB supervisors) at the district level in an attempt to engage large numbers of providers (up to 500+ individual private providers and up to 100 hospitals); 4) established PPM teams at the district level for coordination purposes, but with no concrete scale-up potential or clear incentives for sustained implementation; and 5) produced a financing transition strategy to guide the expected transition from GFATM to domestic financing.

Challenge TB (2014-2019, CTB), the current flagship USAID/Indonesia TB project, operates in 16 districts and is implementing the following activities to improve private sector engagement: 1) assisted in the identification of minimum notification/reporting requirements for private sector notification and collaboration with the NTP; 2) used this minimum reporting requirement to develop a simplified, electronic reporting system (WiFi-TB) and method for all providers (include private) to notify cases, with an eventual link to the future, general electronic TB reporting system (SITB); 3) developed, with NTP, the model of using the sub-district level (puskesmas TB focal point) to engage GPs, whereas the district level would focus on hospital engagement, thus making the numbers more manageable; 4) developed some initial quality assurance tools for TB, including hospital accreditation tools and GP certification tools, although uptake and implementation remains limited; 5) drafted JKN quality standards guideline for TB, though this guideline still has many areas for further improvement and has not been widely implemented; 6) provided technical assistance on distance learning programs for private practitioners, though with limited penetration and with some modules remaining overly long.

The aim of the TB CARE I and Challenge TB private sector related activities has been to increase the percentage of notified TB cases from the private sector, increase the number of private providers certified to provide TB services, and increase the number and percent of TB cases successfully treated in the private sector. Progress on these indicators was sometimes slow, but CTB districts now have an average of 24% notification from the private sector, compared to 9% nationally. Given that Challenge TB adopted an approach that is aligned with the decentralized, district-focused governance of the country’s health system, there is a likely pathway to impact. In 2016, Challenge TB focused on 16 districts and started facilitating a process of district planning for TB. In addition, one year ago, the project began emphasizing sub-district-based engagement with private primary care providers.

The NTP combined the PPM team concept from TB CARE I with the sub-district engagement approach from Challenge TB to develop the district PPM approach. This approach has strong support from the

MoH. Any future interventions should take this historical context into full consideration and build on the MOH’s district PPM concept.

This TBPS project will serve as USAID’s main investment in supporting Indonesia to improve TB services in the private sector. As Challenge TB concludes in September 2019, all private sector related activities, currently under the Challenge TB project, will be transitioned over to the TBPS project. In addition to building on the district-based PPM approach and other lessons from TB CARE I and Challenge TB, TBPS will also utilize market-based approaches such as those outlined in the BCG private sector report (see next section and the Annex).

b. TB private provider analysis

In 2017, USAID/Indonesia commissioned the Boston Consulting Group (BCG) under the Scale for Impact project to undertake a human-centered design analysis of patient and provider experiences in TB private sector care.10 This was conducted in four districts - Medan (North Sumatra province), North Jakarta and East Jakarta (DKI Jakarta province), and Jember (East Java province). High level findings included that: the current provider payment system implemented through BPJS-K was a significant driver of both patient and provider behavior; current national, provincial and district TB programming had limited reach to private providers; and there are significant incentives for patients to prioritize private and secondary care over public and primary care. Finally, there were identified opportunities to improve the quality of private sector TB care to: counter delayed care seeking (especially of clients self-referring to pharmacies); reduce access barriers to diagnostics; overcome the lack of mechanisms and incentives for providers to notify TB patients; and provide treatment adherence support mechanisms for patients.

Four key factors were found to be driving the shift in care-seeking behavior from primary care to secondary care and from public to private providers:

1. Low patient awareness of TB symptoms leads to delayed care-seeking and therefore delays treatment, resulting in more severe cases of TB and a potential increase in care-seeking to hospitals;

2. Patient preferences, e.g., convenience of "one-stop shop" services that include clinical and lab diagnosis plus pharmacy, shorter wait times, and perceived higher service quality and cleanliness.

3. Patient economics, e.g., additional costs covered via BPJS-K at in-house hospital labs and pharmacies.

4. Provider willingness and economics, e.g., GPs do not feel confident about diagnosing TB, and feel the capitation funds that are inclusive of consultation and diagnostics are not sufficient to cover TB care.

Based on the four factors above, stakeholder inputs yielded a number of observations and themes.

First, regulation is not a sufficient lever to drive behavior change in the private sector, but incentives show greater potential to change private sector provider behaviors. Payments through BPJS-K were seen as more influential than potential payments through other input based financing sources coming from the MOH through national priority program funding or from provincial and district

10 Further details can be found in the Executive Summary of the BCG report (see Annex).

governments. Such solutions are needed for the entire TB cascade, including diagnostics, with access to GeneXpert in the private sector being a particular priority. Second, any solutions for the private sector must meet private sector needs by being targeted, simple, and consistent, such as short trainings and tools that emphasize practical steps over theory. Third, patients play an important role in their own care, so information for patients is also critical to influencing provider decisions positively.

Finally, an increased focus is needed on the development of an integrated solution for primary care, both to improve quality and to retain patients in care.

In addition to the BCG study, a set of private provider TB studies planned over the coming two years under a USAID-funded Partnerships for Enhanced Engagement in Research (PEER) grant will provide:11

● A quantitative measure of health seeking pathways and delays (via patient interviews);

● A quantitative measure of diagnostic and treatment behaviors of private providers, as measured by the use of mystery patients; and

● A qualitative (or mixed methods) analysis of provider behaviors and the reasons behind them, as assessed via direct interviews. This will use findings from the first two studies as a basis for questioning the providers.

c. Specialized topics in TB

In addition to the broad-based TB technical assistance and the specific private sector support described above, USAID/Indonesia has provided TB-related support in the areas of community engagement, supply chain management, and drug quality. Details are below.

USAID/Indonesia launched the Community Empowerment of People Against Tuberculosis (CEPAT) (2012-2017/2018) in partnership with the NTP. The principal objective of CEPAT was to support the NTP in “achieving universal access to quality and early TB diagnosis and treatment through community empowerment.” To do this, the project used community mobilization and advocacy to support improved TB care. Three cooperative agreements were awarded to three Indonesian non-government organizations:

Lembaga Kesehatan Nahdatul Ulama (LKNU), Jaringan Kesehatan/Kesejahteraan Masyarakat and Roman Catholic Diocese of Timika. The program was implemented in North Sumatra, West Sumatra, West Java, DKI Jakarta, East Java, Papua and West Papua provinces. Partnering with these Indonesian NGOs, the program focused on increasing people’s awareness on TB prevention and early detection, as well as fostering local commitment to support the national program. A number of these approaches have been taken up under Global Fund, notably via the efforts of Nahdatul Ulama, the parent organization of

LKNU.

For the TB field in general, community linkages remain important for case finding and treatment completion, but the specific model appropriate for Indonesia remains less clear. The use of donor-funded, TB-only cadres is clearly not a sustainable approach. Challenge TB has been encouraging the integration of community-based organizations into district TB planning. But overall the question remains: what community TB approach is really appropriate in a middle income country with extensive social health insurance and increasing urbanization?

11 See study description at: http://sites.nationalacademies.org/PGA/PEER/PEERscience/PGA_174222

Two other related USAID/Indonesia investments include support from centrally managed global mechanisms to help achieve national goals in TB and HIV. The first is the Global Health Supply Chain Program - Procurement and Supply Management (2016 - 2020). This project is tasked with strengthening supply chain management, including strategic planning for supply chain management and commodity security, providing technical assistance related to logistics (e.g. commodity quantification and forecasting, procurement, waste management, quality assurance, product selection), capacity building and transfer of commodity and supply chain management skills for the Indonesian health system, and ensuring an enabling environment for evidence-based decision-making. The second is the Promoting the Quality of Medicines (PQM) Program (2012-2019), which is tasked with improving the quality assurance system for anti-TB medicines. The project provides technical assistance to BPOM (Indonesia Food and Drug Administration) and Indonesian pharmaceutical manufacturers to support WHO prequalification, promotes exportation of first and second-line TB medicines, supports national and provincial/regional drug quality control laboratories with post-marketing surveillance, and builds capacity to incorporate Good Manufacturing Practices (GMP) and monitor quality of program medicines. Investments in PQM have resulted in certification of the National Quality Control Lab to test TB medicines, support for seven TB medicine manufacturers, guideline development and implementation for sampling and testing medicines, trainings for government and industry, and issuance of GMP guidelines.

d. Social health insurance in Indonesia

Currently, USAID is investing in various health financing related activities that will complement and inform the way forward with respect to TB.

Along with the World Bank and under the leadership of the National Social Security Council (DJSN), USAID completed a functional and regulatory review of strategic purchasing under JKN that examined existing legislation and regulations to identify12:

● Which institutions are responsible for carrying out which purchasing functions according to the regulations;

● Whether there are any regulations that conflict with one another;

● How the functions are being carried out, and whether a different allocation of responsibilities across institutions would improve the implementation of the functions.

Phase two of this work will include a deep dive into TB payment systems under JKN. The objectives are to:

● Analyze critical data on JKN-related service utilization, claims, referrals, and total spending on TB diagnosis and treatment to understand the consequences of current provider payment systems for these services, working closely with the Research and Development Unit of BPJS-K, MOH- PPJK, and MOH-NTP.

● Reach consensus on the feasibility of strategically purchasing these services under JKN from a diverse set of providers and propose new provider payment options for TB. Options will be discussed based on the BPJS-K analysis and stakeholder understanding of the financial and

12 Report will be made available publicly before USAID releases a solicitation for TBPS.

operational feasibility as well as potential impact on provider behavior of introducing new payment models.

● Build the capacity of the Research and Development Unit of BPJS-K to conduct budget impact analysis of new purchasing and provider payment proposals and continuously monitor and improve the processes involved in the strategic purchasing of TB services to meet national goals.

USAID is also working with the Vice President’s Office - National Team for the Acceleration of Poverty Reduction (Tim Nasional Percepatan Penanggulangan Kemiskinan - TNP2K) to complete a financial viability analysis, equity and benefit incidence analysis and fiscal space analysis for JKN. Over four years into JKN implementation, the program is believed to have created business opportunities for the private sector, increased the patient population accessing care, and opened competition among health care providers. Thus, the government would like to assess changes in the health market caused by the introduction of JKN. USAID is supporting a multi-province private hospital facility-level survey to gather quantitative data on changes to service delivery volume, types of services offered, human resource, infrastructure, and the finances in response to JKN. This survey also includes a qualitative component that assesses the perception and behavior of health care workers and administrators in these facilities since the introduction of JKN. Primary healthcare facilities are not included in this survey. Notably, related to TB, the following information is being collected13:

● Whether the facility offers TB services or not; if they do, what type (diagnostics as well as treatment; referral patterns); if not, why not.

● Number of GeneXpert machines the facility has, and number of tests it conducted in a specified year.

● Whether the service (GeneXpert) was offered, and whether the equipment was functional at the time of data collection.

● Availability of TB diagnostic test protocol and/or standard operating procedures at the facility.

● Which cadre leads TB diagnostic services.

Along with MOH-PPJK, USAID is working on the institutionalization of national, provincial and district health expenditure tracking systems. National Health Accounts 2015 are soon to be released and for the first time in Indonesia will include disease distribution analysis, including for TB14.

In order to better understand how local governments have adopted and adapted national health financing laws, i.e., the use of funds including JKN capitation and Dana Alokasi Khusus (DAK) (special allocation funds in support of national priorities) at the PHC level, USAID has invested in conducting implementation research along with the University of Gajah Mada.

Finally, USAID has seconded to DJSN a senior health economist to support the operationalization of and ongoing improvements to the JKN program.

TBPS will work very closely with ongoing USAID-funded efforts on health financing, specifically with the work on strategic health purchasing, but act as an advisor and supplementer of TB-specific information, rather than a lead on discussions with national entities involved in health financing. TBPS

13 Report will be made available publicly before USAID releases a solicitation for TBPS.

14 Report will be made available publicly before USAID releases a solicitation for TBPS.

http://www.tnp2k.go.id/ districts may be used as pilot sites for testing and improving provider payment systems for TB in collaboration with USAID health financing activities, MOH and BPJS-K.

C.6 THE VISION FOR USAID’S ROLE IN TB PRIVATE SECTOR CARE IN INDONESIA

The scale of the TB private sector issue calls for a dedicated effort in this area. USAID intends to focus its approach to ensure TB private sector actors are supported by the health system, their access to diagnostics is increased, they can better facilitate patient notification, and they can provide quality treatment to patients.

This effort will complement and leverage the existing activities already underway, like the NTP’s district PPM strategy. The previous experience with project-based PPM efforts, in which the end of project support led to the end of program achievements, emphasizes the need for a new approach. Here, the emphasis is on building upon and using existing systems, including JKN, to ensure institutionalization and country ownership.

To build sustainability, this work should include GOI entities involved in both health financing (BPJS-K and MOH-PPJK) and TB (NTP) at all steps. Moreover, the process should capacitate these entities, so they are better equipped to undertake the inevitable future adjustments and to negotiate with each other using a common language.

C.7 TECHNICAL APPROACH

a. Core Operating Principles

The following core operating principles will guide USAID’s investments under the TB PS activity:

1. Introduce system improvements, rather than stand-alone, unsustainable interventions, to break through barriers to progress in achieving TB outcomes. Interventions should also reflect the potential roles played by different actors in the existing health system.

2. Align all activities and efforts along a critical path to achieve sustainable results, focusing on a limited number of efforts critical to achieve desired TB outcomes.

3. Provide catalytic support for system improvements by providing critical information and evidence to inform problem definition, impact measurement, and programmatic and policy decisions at all levels.

4. Influence systems operating at scale to improve population access to and utilization of essential, evidence-based, services that drive the diagnosis, notification and appropriate treatment of tuberculosis.

5. Maximize the use of local, regional (Association of Southeast Asian Nations - ASEAN) and global counterparts and resources to build institutional relationships and partnerships that last beyond USAID project assistance.

b. Overarching Approach

A significant challenge in implementing TB programs in Indonesia arises from political and financial decentralization. The majority of domestic health financing is budgeted at the district level, and there is no obvious way to disseminate normative programming guidance effectively to over 500 local governments. Similarly, best practices tend to remain in isolated areas, and often are not spread even to other districts in the same province.

Given the limited resources available for implementation in a large country, TBPS will focus on specific geographical areas (see Section C.7.d). This would result in limited epidemiological impact if activities are suitable only for a project-driven context in project districts. Therefore, to maximize the chance of sustaining success:

● Project inputs should not add new interventions that do not have a local “owner” -- the project should work with and strengthen the institutions and mechanisms that already exist;

● The health insurance infrastructure should be seen as an opportunity to guide policy and practice in a system-wide way; and

● Active dissemination will remain a critical need for many other important interventions (outside of the health financing lever), notably the work on engaging and socializing private providers).

To respond to this need for dissemination, TBPS will include a strong theory of change of how project gains will spread to other districts beyond USAID specific geographical areas, with a deliberate approach to dissemination and sustainability. TBPS will have two geographically distinct priorities: ensuring significant gains in major TB indicators in its project districts; and consciously creating a path for significant uptake of its interventions in non-project districts.15 This second priority should not dilute the physical presence of the project in its project districts, but instead rely on techniques such as cross-learning, mentorship, and capacitation of provincial leadership, and the results of these efforts should be closely monitored and evaluated.

To facilitate the spread of project impacts, it will be the learning approach and not the implementation model that is intensive, with major investments in measurement, learning, stakeholder engagement, communication and spread. This includes understanding and documenting varying needs and approaches across different districts. The district selection (see Section C.7.d) is designed to include variation, including variation in the current performance in private sector engagement, the number, concentration and nature of private sector providers, and the level of urbanization. TBPS will be expected to take this variation into account in designing interventions suitable to each district, and to consider additional variation such as the type of local organizations that might be engaged to implement various aspects of the activity.

TBPS will also document these designs, variations, associated outcomes, and any necessary adaptations thoroughly. For example, in a district where the private sector is already contributing a significant proportion of TB case finding, it will be important to determine the extent to which this contribution is already institutionalized, and the amount of additional private sector case finding that may still be possible. In a district that is currently less successful, the priority will be to understand and document the

15 See http://emasindonesia.org/assets/up/2017/03/Expansion-and-Replication-Report.pdf for one example of this kind of thinking.

http://emasindonesia.org/assets/up/2017/03/Expansion-and-Replication-Report.pdf process by which this pattern can be changed, both in districts with and without direct TBPS activity support.

c. Technical Elements

Overview of goal and objectives The goal of the USAID TBPS activity is to increase the number of care-seeking clients in the private sector who are correctly diagnosed, notified, and have successfully completed TB treatment. This goal aligns with a major action area of the NSP 2016-2020 of the National TB Program of the GOI.

This project will address the gaps in the current NTP program identified by surveys and analyses, which indicate that a large percentage of TB clients seek care in the private sector, but are not being notified or receiving quality-assured care. Given the scope of this issue, the project will aim, at least initially, to establish the basics of TB control in the private sector, before considering whether and how to introduce more specialized TB topics to the private sector, such as screening for comorbidities. This project will operate in the existing health system and ecosystem of JKN, under the current legislation and regulations, targeting private providers and private sector care-seeking clients, while ensuring that efforts are complementing NTP’s structure and efforts in the public system.

USAID’s support will facilitate and enable the development, implementation, and evaluation of strategies that strengthen the private primary healthcare level to appropriately provide the continuum of TB care to care-seeking clients while reducing the burden and costs to the GOI at the secondary care level. This technical approach is anticipated to change private providers’ and patients’ behaviors by achieving the following three objectives:

1. Increase private sector access to TB diagnosis and facilitate TB patient notifications;

2. Increase the TB treatment success rate in the private sector; and

3. Increase uptake of improved private provider engagement mechanisms in non-project districts.

Underlying these objectives will be activities that support private sector TB providers and patients in the area of health financing and information systems.

USAID envisions that, with the support of this new project, private providers and clients will be better integrated into the overall health system, building greater cooperation and collaboration between the NTP, the province and district health systems and the private sector.

Objective 1: Increase private sector access to TB diagnosis and facilitate TB patient notification.

This objective responds to a leading imperative in TB care and prevention globally - to find the “missing” TB patients so that they can receive quality care. This objective establishes three important intermediate results that are prerequisites for achieving significant progress in the second objective. The objective-level indicators are:

● Number and percentage of TB patients notified from the private sector in project areas

● TB treatment coverage (notified / estimated incidence) in project areas

IR1: Patient pathways improved and time between care-seeking and diagnosis decreased Patients can be diagnosed and put on treatment earlier by: (a) increasing referrals from pharmacy and labs; (b) improving provider awareness, confidence and competence in delivering quality TB services, including both diagnosis and treatment; and (c) introducing provider incentives aligned with desired patient pathways.

Methods to improve provider awareness, competence and confidence may include shorter, simpler, and more practical training modules and job aids, linked to continuing medical education points or other recognition by professional associations, or other approaches. Previous approaches in this area were often oriented to public rather than private sector needs, and with no path to institutionalization and scale-up.

Approaches used by TBPS should overcome these previous challenges and focus on solutions that are private sector centric (market based approaches) and institutionalized.

Ongoing provider awareness and monitoring is also needed: for this function, the district PPM approach relies on puskesmas-based staff and district-based staff to reach GPs and hospitals, respectively. Offerors should outline ways to strengthen this general approach and ensure its uptake in non-project districts.

For incentives, JKN provides a possible mechanism to mainstream any approach. Currently in Indonesia, private primary health care providers (GPs) are not incentivized to provide a seamless TB diagnosis and treatment experience. At the PHC level, the lack of specific payments for TB diagnosis and drugs outside of the capitation payment seems to be a barrier, especially for a condition that is burdensome to diagnose, but also relatively uncommon for a GP (although the specific reimbursement of some diagnostic services at the new “primary care plus” facilities may provide a partial solution). Many clients either self refer or are referred to secondary care facilities.

Therefore, the TBPS activity will work with USAID Health Financing activities to pilot private provider payment models…