RFI_-_Maternal_and_Newborn_Health_Activity.pdf

REQUEST FOR INFORMATION

USAID/Indonesia Maternal and Newborn Health Activity

Subject: Request for Information (RFI)

Date of issuance: January 25, 2016

Response due: February 12th, 2016 (2:00 p.m., Jakarta time)

Response to: proposals-indo@usaid.gov

This is a Request for Information (RFI). 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 solicitation or synopsis. It should be noted that responding to this RFI will not give any advantage to any firm or organization in the subsequent procurement. Responses will be held confidential. Proprietary information should not be sent.

This RFI intends to obtain information about interests, capabilities, and market information related to the enclosed draft statement of work in order to inform the design of a future mechanism. USAID may revise the concept based on comments received, but it is not obligated to do so. This RFI is open for comments from any interested US and Non-US Organizations.

Responses should be sent using the cover page as Attachment No. 2 to this RFI. USAID values concise, issue-specific responses. 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.

Responses should be no more than 5 (five) pages in length (not including the cover page/Response Form). Responses to the RFI must be written in English, shall use only 8 ½” x 11” paper, single spaced, 11pt font. Number each page consecutively.

Send responses to this RFI via email to proposals-indo@usaid.gov with the subject title “Request for Information (RFI): USAID/Indonesia Maternal and Newborn Health Activity”, no later than the date/time stated above. You will only receive an electronic confirmation acknowledging receipt of your response, but will not receive individualized feedback on any suggestions.

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.

/s/ Sandra Savage Contracting Officer USAID/Indonesia Attachment:

1. Draft Statement of Work

2. Response Form

Attachment 1

USAID/INDONESIA

REQUEST FOR INFORMATION (RFI)

FLAGSHIP MATERNAL AND NEWBORN HEALTH ACTIVITY

PURPOSE OF THE RFI

Noting the practical issues of designing and implementing a maternal and newborn health activity centered around engaging a wide array of stakeholders through an open innovation process, USAID/Indonesia is soliciting comments from individuals, companies, and organizations with regard to the activity statement of work (SOW).

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 and refer to the core operating principles, approach and technical areas of interest to USAID/Indonesia.

Questions to Consider for All respondents:

Do you have any general feedback on the SOW?

What is unclear in the SOW?

Does the approach and related capabilities accurately capture the breadth of activities and skills necessary to implement open innovation programming, work with entrepreneurs and innovators, and address other objectives related to moving the needle on maternal and newborn mortality in Indonesia?

Do you have any feedback on the highlighted technical focus areas?

What do you think are useful examples from Indonesia or elsewhere of similar approaches being taken to address operational issues in the health sector?

In addition to a Chief of Party, what do you see as the most necessary positions in the management of this activity?

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.

USAID/INDONESIA

ACTIVITY STATEMENT OF WORK

FLAGSHIP MATERNAL AND NEWBORN HEALTH ACTIVITY

ESTIMATED RANGE: $55 - $65 million

IMPLEMENTATION PERIOD: FIVE YEARS

1) PURPOSE

Contribute to national goals to reduce maternal and newborn mortality by providing catalytic support to improve essential maternal and newborn services targeting the poorest and most vulnerable.

2) BACKGROUND

Socioeconomic Context

With a population of more than 250 million, Indonesia is the world’s fourth most populous country. Its 34 provinces are divided into more than 530 decentralized districts and municipalities where more than 700 languages are spoken. Categorized by the World Bank as a lower middle income country, it is the largest economy in Southeast Asia and a member of the G-20. It has a gross domestic product (GDP) of USD$3,475 per capita (WDI 2015, 2014 estimate). Its total health expenditure in 2012 of 3.1 percent of GDP places Indonesia in the lowest dozen countries in the world for expenditure on health.1 Approximately 45 percent of this expenditure comes from out of pocket spending (Indonesia National Health Account 2012).

Although there has been a net decrease in both the number and the proportion of poor people over the past five years, 28 million people in Indonesia still live in extreme poverty. Around 40 percent of the population (100 million people) is considered either poor or vulnerable (i.e. living on USD$2 a day or less) (WDI 2015, 2014 estimate). The poor and near poor in Indonesia face a very different reality in terms of their access to health care than their wealthier neighbors.

Maternal and Newborn Health in Indonesia

Problem Description

Despite Indonesia’s growing economy, many of its citizens lack access to essential human services such as quality health care, clean water and sanitation services, and an accountable and service-oriented local government. Indonesia’s maternal mortality ratio has remained stubbornly high, now higher than most other countries in the region and other countries at a similar stage of development. Child mortality has steadily declined, but newborn death rates have remained stagnant and are a growing proportion of all deaths – now at almost 50 percent of all under-five child deaths (IDHS, 2012). With great wealth disparity in Indonesia, these issues disproportionately affect those poorest and most vulnerable. And yet, the nature of these problems – both determinants and solutions – are well understood globally and in Indonesia, as described in the following sections.

1 World Health Organization Global Health Expenditure database, accessed via World Bank database, data for 2013.

Maternal mortality in Indonesia has not followed the pattern of decline commonly seen in many countries under similar circumstances. Maternal mortality estimates from the Indonesia Demographic and Health Survey (IDHS) indicate that maternal mortality actually increased over recent years, from 228 maternal deaths/100,000 live births in the 2007 IDHS to 359/100,000 in the 2012 IDHS. A corrected estimate based on Indonesia’s 2010 census is 263/100,000 live births – with other estimates based on the 2010 census ranging from 260 to 346. While these findings and estimates of maternal mortality ratio have sparked intense controversy and dialogue about Indonesia’s true level of maternal mortality, it is clear that maternal mortality is not declining, and that Indonesia will not reach its Millennium Development Goals (MDG) in this area. The situation is best summarized in the following figures:

Figure 1: Evolution of Maternal Mortality Ratio in Indonesia, and Comparison to Selected Asian Countries

Sources: Indonesia Demographic and Health Surveys (Indonesia, black line and dots) and most recent World Bank-UN estimates of MMR for other countries (blue bars).

360 390

500 1986 1991 1995 2000 2005 2010 2015

M at er n al M o rt al it y R at io

Figure 2: Comparison of Maternal Mortality Rates – Indonesia in 2010 (range of estimates) Compared to Countries at Similar Gross National Product (GNP) per capita, Purchasing Power Parity (PPP)

Sources: 2012 Indonesia DHS (359) with confidence interval, 2010 Indonesia Census corrected estimate of MMR (263, NAS/AIPI Report), World Bank-UN estimates of MMR for other countries, World Bank estimates GNP PC PPP at

(http://data.worldbank.org/indicator/NY.GDP.PCAP.PP.KD?page=4)

These two figures clearly illustrate that maternal mortality in Indonesia is far higher than would be predicted based on the experience of many other countries. Indonesia’s MMR is among the highest in Asia – even higher than the countries of South Asia or less developed Southeast Asian countries such as Cambodia. Figure 2 illustrates that other countries that have reached a similar GNP PC (PPP) since 1990 have a MMR in a range below 100, with a median of 44 for Asian countries – in all cases a fraction of any estimate of Indonesia’s MMR. The significance of this in terms of lives lost is great. At an MMR of 263/100,000, 12,500 women die in Indonesia every year from pregnancy-related causes; at a MMR of 359, that number is over 17,000. By contrast, if Indonesia’s MMR were the Asian median for countries at a similar GNP PC (PPP), the estimated number of deaths would be 2,100 – reduced up to15,000, or almost 90 percent fewer, maternal deaths every year in Indonesia.

This cross-country comparison also illustrates that maternal mortality can be successfully reduced in a variety of environments, and as well 25 years ago as today. Reductions in maternal mortality have not required major technological breakthroughs or unusual circumstances – rather, it requires the effective provision of essential services to women and mothers.

Historic progress reducing neonatal mortality has stalled at 19/1,000 live births (Figure 3), reflecting the lack of progress in maternal mortality. Newborn deaths and those of mothers are inextricably linked, with many common determinants and similar solutions in the provision of essential health services.

Figure 3: Neonatal Mortality Rate – Progress Stalled over 2 Decades

Source: Indonesia DHS; all rates per 1000 live births

Child Mortality

Infant (without newborn)

Neonatal

Figure 4: Comparison of Neonatal Mortality Rates – Indonesia in 2010 Compared to Countries with Similar GNP per capita, PPP

Sources: 2012 Indonesia DHS, World Bank-UN estimates of NMR for other countries, World Bank estimates GNP PC PPP at (http://data.worldbank.org/indicator/NY.GDP.PCAP.PP.KD?page=4)

As seen with maternal mortality, Indonesia’s neonatal mortality rate is also a lagging indicator when compared to other countries that achieved similar GNP PC (PPP) since 1990. While not as dramatic as those differences seen in MMR, Indonesia’s NMR at 19 is far higher than the Asian median in this figure – a NMR of 11 – and higher than any other single country reaching a similar level of GNP PC (PPP). The real significance of this difference is about 40,000 neonatal deaths each year in Indonesia – over 90,000 at the current estimated NMR of 19, which would be reduced to 52,000 at a NMR of 11.

Evidence-Based Interventions are Known and Feasible

The direct causes2 and evidence-based interventions to reduce maternal and neonatal mortality are well understood, well developed with many years of experience, and feasible to implement and in a way that could reach the poorest and most vulnerable in Indonesia. The main causes of maternal and neonatal mortality in Indonesia generally follow the global pattern, in which a few, well understood primary causes account for the majority of deaths. Over the last decade, there has been a dramatic increase in literature summarizing existing evidence, analyzing priorities in terms of proportion of mortality that may be averted, cost-effectiveness and many aspects of operations and implementation strategies – for both newborn and maternal health3. Policies in Indonesia are consistent with international norms and reflect this knowledge of evidence-based solutions. And Indonesia has demonstrated progress in key indicators. For example, skilled birth attendance4 has increased sharply over the past 25 years, with 83 percent of mothers delivering with a skilled professional in the most recent survey (IDHS, 2012). Even so, progress to reduce maternal and newborn mortality has stalled.

Local Information to Inform Program and Policy Priorities is Inadequate

Most remarkable is the poor state of information in Indonesia to guide program and policy decisions. Almost all cause of death data from Indonesia comes from deaths in facilities – and it is generally believed that less than half of maternal deaths are counted in routine statistics at the district level and higher5. This suggests that many deaths, especially those outside of health facilities, are not reported or reviewed, and that there may be important and unknown biases in available data on cause, place and circumstances of death. For example, based on cause of death data available in Indonesia, it appears that abortion-related deaths may be very low, or this cause of death may simply be rarely reported. Therefore, all current information on maternal and newborn deaths must be viewed as indicative rather than fully descriptive.

In the case of newborn deaths, the pattern in Indonesia generally follows what would be expected when the NMR is less than 20 – with increasing proportion of deaths due to birth-related causes (asphyxia) and prematurity/low birth weight, and a lower proportion due to sepsis (infection).

There are indications that proportions among these main causes of death may deviate from the global average – with a rate of premature birth over 15 percent in Indonesia, compared to 11 percent globally, and a persistently high rate of low birth weight – 12 percent or higher. The

2 Most common direct causes of mortality are Maternal: pre-eclamsia/eclampsia, post-partum hemmorrhage, and sepsis; and Newborn: Birth related/asphyxia, low birth weight/prematurity, and sepsis 3 For example, see Lancet Series on Neonatal Survival and Maternal Survival, accessed at: http://www.thelancet.com/series/neonatal-survival and http://www.thelancet.com/series/maternal-survival . These series continue to be updated, summarizing developments and evolving recommendations, for example in http://www.thelancet.com/series/everynewborn 4 Skilled Birth Attendant defined as category of provider; actual skill was not assessed 5 USAID analysis of available data comparing the range of national estimates of mortality to those deaths captured by routine reporting statistics, the 2010 census, and the sample registration system indicate that these capture between 40 and 55% of all deaths, almost all from facilities.

rates of prematurity and low birth weight are very important to understand, as 80 percent or more of neonatal deaths are associated with these conditions, even where they are not the direct causes of death. Again, these rates are not known with a high level of confidence, and if they are confirmed, have significant implications for program and policy priorities.

There are scant data on maternal nutritional status, which influences both maternal and newborn survival. The national level of low birth weight – the number one risk factor for newborn death -is 12 percent (as reported by the NIHRD, MOH), an average that masks much higher incidence in certain regions, for example, 27 percent in Papua and 24 percent in West Papua (Dickey et al.

2010). The high prevalence of maternal anemia, 37 percent, may be partly responsible for the lack of progress in reducing neonatal deaths; and one study suggested that 20 percent of early neonatal deaths in Indonesia could be attributed to a lack of iron and folic acid supplementation during pregnancy. Moderate to severe anemia during pregnancy also increases a woman’s risk of postpartum hemorrhage, one of the leading causes of maternal mortality.

Global Priorities to Reduce Maternal and Newborn Mortality are Well Understood

With an increasing global focus on neonatal and maternal mortality, and priorities to accelerate progress, many review articles, meta-analyses and entire volumes have been published over the past decade. These describe in detail the anticipated reduction in mortality from effective intervention - both as individual interventions and packages - including how the priority among interventions may vary according to the underlying mortality rate6. In all cases, a small number of well-understood, life-saving, evidence-based interventions can, if effectively delivered to mothers and newborns with sufficient quality, prevent the vast majority of deaths. However, some of the most compelling empirical evidence is illustrated in Figures 2 and 4 above, where countries comparable to Indonesia in GNP PC (PPP) have maternal and neonatal mortality levels closer to those of the U.S. than to those of Indonesia.

Policies in Indonesia are consistent with global knowledge of what works to reduce maternal and newborn mortality. For example, the most recent GOI Maternal Health Strategy and the Indonesia Newborn Action Plan are exemplary in setting forth evidence-based priorities to address the main causes of maternal and neonatal mortality in Indonesia. Maternal and newborn mortality will be reduced in Indonesia when known, life-saving, evidence-based interventions – all consistent with existing policies - are effectively implemented and reach the poorest and most vulnerable in Indonesia.

6 See Lancet Series on Neonatal Survival and Maternal Survival for summaries, accessed at: http://www.thelancet.com/series/neonatal-survival and http://www.thelancet.com/series/maternal-survival . These series continue to be updated, summarizing developments and evolving recommendations, for example in http://www.thelancet.com/series/everynewborn

Equity Considerations: Reaching Those Most at Risk - the Poorest and Most Vulnerable

National and regional averages, though themselves too high in the case of MMR and NMR, obscure important variation among sub-populations. Some –the poorest and most vulnerable described here– have much poorer access to services and much higher rates of disease than the majority of the population living in better circumstances. The metrics describing the poorest and most vulnerable are numerous, intertwined and highly correlated – poverty, income, wealth, social class or group, type of employment, education, poor access to services, location of residence, and others.

A now-standard methodology to evaluate equity concerns is to analyze health outcomes and service access by wealth quintiles – quintiles established by a standard methodology based on household possessions78. The general pattern observed in many countries is also seen in Indonesia, where the bottom two quintiles – that is the poorest 40 percent of the population – have the greatest health burden and least access to services.

Figure 5: Under Five Mortality Rate as Deaths/100,000 live births per year and Delivery in

Health Facility as percent of All Births.

Source: Indonesia DHS, 2007

Mortality outcomes and use of essential health services are closely related to wealth quintile.

Additional quintile analyses of indicators of maternal care from IDHS 2012 data may be accessed in a more extensive report, “Increasing access for the poor to facility-based birth in

Indonesia.”9

7 DHS Comparative Report No. 6: The DHS Wealth Index, Shea Oscar Rutstein and Kiersten Johnson,2004.

8 D. R. Gwatkin, S. Rutstein, K. Johnson, E. Suliman, A. Wagstaff, and A. Amouzou, “Socio-economic differences in health, nutrition, and population within developing countries: an overview.,” Niger. J. Clin. Pract., vol. 10, no. 4, pp. 272-82, Dec. 2007; n.b. Gwatkin has published extensively on this subject.

9 “Increasing access for the poor to facility-based birth in Indonesia”: Report Download Link

77.00

13.6

59.00

31.7

44.00 47.9 36.00

61.7

32.00

83.3

Under Five Mortality Rate Delivery in Health Facility

Poorest Poorer Middle Richer Richest

Figure 6: Maternal Mortality and Essential Services – Disparities across Wealth Quartiles in Banten Province

Source: C. Ronsmans, et. al., Professional assistance during birth and maternal mortality in two Indonesian districts, Bull World Health Organization. Jun 2009; 87(6): 416–423.

These figures illustrate several striking, and strikingly consistent, findings that are important to guide public health priorities. Firstly, poorer quintiles – typically the lowest two – have much higher rates of mortality and lower access to services than those better off. Neonatal mortality is 3 times higher in the poorest wealth quintile than among the top wealth quintile in Indonesia (IDHS). And this pattern is seen for all age groups under-five, as well as for maternal mortality.

Maternal mortality appears to be even more sensitive to wealth differences than neonatal mortality. In a study from Banten province, the only one of its kind in Indonesia, 40 percent of maternal deaths occurred in the poorest 25 percent of the population studied – and had a Maternal Mortality Ratio, at 700, higher than all but a handful of African countries, and almost twice that of Afghanistan10. Comparing urban and rural averages is also deceptive. Though the urban average for home deliveries, 19% of all births, is much lower than the rural average, 52% of all births, the poorest have high rates of home birth in both areas (53% urban vs. 73% rural)11.

The combination of a sharper gradient across quintiles and a higher proportion of urban population in upper wealth quintiles means that urban averages for health measures are always better than rural averages. But the difference in averages obscures the similarities between the

10 “Trends in Maternal Mortality” at http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1 11 IDHS 2012 and “Increasing access for the poor to facility-based birth in Indonesia”: Report Download Link urban and rural poor. The pernicious cycle of increased burden of disease, financial stresses of paying for health services and losing income, and poor access to preventive and curative services create a classic poverty trap.

Indonesia has at least two distinct equity problems. The most commonly recognized problem is the high rate of poverty, with associated poor health and education indicators, seen in Eastern Indonesia. The overall poverty rates are higher, as are mortality rates. At the same time, because of population size, there are more people living below the poverty line in West Java, for example, than in all provinces of Eastern Indonesia combined.

Table 1: National and Regional comparisons: Maternal and Neonatal Mortality and Poverty

Measure

(all 2010)

National Region Sumatra Java-Bali Kalimantan Sulawesi Eastern

Indonesia12

Population 237,641,326 50,630,931 140,501,347 13,787,831 17,371,782 15,349,435

% all

Indonesia 21.3% 59.1% 5.8% 7.3% 6.5%

MMR 263 251 222 290 430 382

Maternal

Deaths

12,390 2,820 5,610 870 1,630 1,460

% all

Indonesia 22.8% 45.3% 7.0% 13.2% 11.8%

NMR 19 21 18 21 19 29

Neonatal

Deaths

85,076 22,072 40,935 5,574 6,573 9,369

% all

Indonesia 22.9% 48.1% 6.6% 7.7% 11.0%

Poverty rate

13.1% 13.1% 12.5% 7.4% 14.0% 22.9%

Poverty

Burden (% all Indo)

21.4% 56.4% 3.3% 7.6% 11.3%

Sources: Maternal Mortality Data based on 2010 Census (NAS/AIPI report - note that only census-based estimates provide regional estimates; IDHS provides only national estimate); Newborn Mortality from 2012 DHS; Poverty rates from GOI BPS.

12 Eastern Indonesia here includes Papua, West Papua, Maluku, North Maluku, NTT and NTB

From Table 1 we can see that the majority of Indonesia’s population and poverty is in Java-Bali, as well as 45 percent of the national burden of maternal mortality. While Eastern Indonesia accounts for a smaller proportion of maternal deaths and poverty – between 11 and 12 percent -the poverty rate in Eastern Indonesia approaches twice that of Java-Bali (22.9 percent vs. 12.5 percent) and the MMR and number of maternal deaths are disproportionately high. A similar pattern is seen in neonatal mortality.

Overview of the Indonesian Health System

The health sector in Indonesia has undergone major policy changes in recent years.

Decentralization reforms beginning in 1999 have resulted in the devolution of responsibility for health service delivery to the district and municipal levels. Key pieces of legislation that affect the health sector include Law 23/2014 and the Village Law, both of which provide more detail on the roles and responsibilities of the national, provincial and district level governments. Law 23/2014 increases the role of provincial oversight as districts take on responsibility for rolling out revised minimum service standards, and the Village Law empowers village governments by providing opportunities for additional resource flows pending successful proposals by districts on how they would use such health funding.

The institutional context for health and health-related matters is unusually complex. In addition to the Ministry of Health (MOH), major actors include the National Social Health Insurance Provider [Badan Penyelenggara Jaminan Sosial-Kesehatan (BPJS-K)], the Ministry of Home Affairs and the National Family Planning Board [Badan Kependudukan dan Keluarga Berencana Nasional (BKKBN)]. Important bodies that guide or influence these actors include the Ministry of Finance and the National Council for Social Protection [Dewan Jaminan Sosial Nasional (DJSN)]. The National Team for the Acceleration of Poverty Reduction [Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K)], currently under the Vice President’s Office, and the Ministry of Social Affairs work together in developing methodologies and processes to identify and target the poorest and most vulnerable populations in the country.

In 2014, the country adopted the goal of achieving universal health coverage (UHC), aiming to reach the entire population by 2019. Currently, the GOI is consolidating all existing social health insurance schemes into one umbrella program, Jaminan Kesehatan Nasional (JKN), under the purview of the single payer social security agency BPJS-K. A “Road Map towards National Health Insurance Coverage 2012-2019” summarizes the government’s vision and plan for achieving UHC. The National Council for Social Protection [Dewan Jaminan Sosial Nasional (DJSN)] is a 15 member council appointed by the President and tasked with overseeing the implementation of the National Social Security System, including the national social health insurance program. Please refer to, Indonesia Rapid Health System Assessment, 2015, to learn more about the JKN program13.

BPJS administered social support programs, including JKN, are targeted at the poorest 40 percent of Indonesians, who should receive a Penerima Bantuan Iuran (PBI) card indicating eligibility for services. In the case of JKN, those holding PBI cards receive a full subsidy and are therefore eligible to receive JKN-covered health services free of charge.

A potentially powerful lever in health care delivery is the private sector. Indonesia has a growing private sector, operating at both the primary health care and hospital levels. “Dual practice” is legal and common in Indonesia, and about 70 percent of health center (or puskesmas) physicians and 93 percent of midwives provide private services in addition to their practice in the public sector. The number of private primary health care facilities in Indonesia is unknown. A large and growing number of both private and faith-based hospitals also exist. As of 2014, there were 1,436 private for-profit and not-for-profit hospitals in Indonesia (Jones, Singgih and Suwandi 2014). Under the JKN program, private sector facilities contracting with BPJS-K can be reimbursed for services, creating a new opportunity that private sector actors are interested in exploring. 14

USAID’s Prior Experience in Maternal and Child Health

USAID has supported bilateral maternal and child health programs with the Government of Indonesia (GOI) for at least 25 years. Beginning with a project in Kalimantan in the 1990s, USAID focused on improving the lifesaving skills of midwives and increasing the utilization of skilled providers. The Maternal Neonatal Health Project followed in 1999, the primary contributions of which were an improvement in the management skills for normal delivery; the development of a manual that supported normal delivery, which became the national standard;

and planning for all pregnancies. USAID’s next maternal health flagship project (the Health Services Project or HSP) began in 2005, with a focus on improving the quality of service delivery among midwives, increase the use of skilled birth attendants and, in the last year of the project, a focus on increasing facility deliveries and improvement of hospital services. The HSP ended in September 2010. A bridging maternal health project, the Maternal and Child Health Integrated Project (MCHIP), was implemented from March 2010 through 2012. During implementation in three districts, it continued initiatives in support of normal delivery, using

13https://dec.usaid.gov/dec/content/Detail.aspx?ctID=ODVhZjk4NWQtM2YyMi00YjRmLTkxNjktZTcxMjM2NDB mY2Uy&rID=MzcwODQ4 14“Ripe for Investment: the Indonesian health care industry post introduction of Universal Health Care Coverage.”

EY report, July 2015, http://www.ey.com/Publication/vwLUAssets/EY-ripe-for-investment-the-indonesian-health-care-industry/$FILE/EY-ripe-for-investment-the-indonesian-health-care-industry.pdf evidence-based interventions to promote quality of services, and increasing the use of skilled providers.

The EMAS (Expanding Maternal and Newborn Survival) activity began in September 2011 and will end in March 2017. In 2014, a midterm review was conducted of the EMAS project15. With a goal of contributing to national maternal and neonatal mortality reduction, EMAS has worked directly in six high population, high burden provinces to develop effective approaches to improve the quality of maternal and newborn services in health facilities and improve referral for maternal and newborn emergencies – supported by information, communication and technology (ICT) innovations and local governance activities.

Current USAID Strategic Framework

This flagship maternal and newborn activity is aligned with USAID/Indonesia’s Country Development Cooperation Strategy (CDCS)16 and with USAID’s global priority initiative, Ending Preventable Child and Maternal Deaths (EPCMD). The current CDCS seeks to reorient USAID strategic engagement in Indonesia and provides an opportunity to address extreme poverty.

USAID/Indonesia’s CDCS 2014–2018 has four integrated Development Objectives (DOs):

DO 1: Democratic governance strengthened DO 2: Essential human services for the poorest and most vulnerable improved DO 3: Global development priorities of mutual interest advanced

DO 4: Collaborative achievement in science, technology, and innovation increased

This flagship activity falls under the Essential Services (ES) Project, which implements two of the intermediate results (IR) under Development Objective 2: Essential human services for the poorest and most vulnerable improved 1) IR 2.1: Services to reduce preventable maternal and child deaths improved and 2) IR 2.3: Governance of essential services at the local level strengthened. This activity addresses two of the three expected results of the Essential Services Project:

● Contribute to a 25 percent Reduction in Maternal Mortality Ratio at the national level

● Contribute to a 25 percent Reduction in Neonatal Mortality Rate at the national level

This activity also contributes to the remaining DOs. In support of DO1, it will enhance accountability, governance and civil society participation to improve availability and use of

15 Access EMAS Mid Term Evaluation Report at: http://pdf.usaid.gov/pdf_docs/pa00jz5q.pdf 16 https://www.usaid.gov/indonesia/cdcs essential services among the poorest and most vulnerable. Potential investments made under this procurement may support DO3 with improved quality of care and health system functioning that would contribute to results under the Infectious Disease project (DO3). Additionally, with core operating principles that include supporting innovation in program and operational approaches and providing critical information and evidence to inform program and policy decisions at all levels, this activity is closely aligned with the goals of DO4.

Relationship of this Procurement to Global Movements

Progress on the MDGs has been uneven and the 17 newly ratified Sustainable Development Goals (SDGs) aim to better address the needs of the world’s most vulnerable. Indonesia’s own ambitious plan of achieving UHC by 2019 echoes that of SDG 3, which includes achieving UHC and access to quality health care, reducing the global maternal mortality ratio to less than 70 per 100,000 live births, and ending preventable deaths of newborns with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 by 2030. USAID’s own EPCMD initiative is also embraced in SDG 3, which encourages collaboration to save the lives of 15 million children and nearly 600,000 women by 2020 in 24 focus countries, including Indonesia.

A global consensus is emerging that underscores the need for countries to have cohesive, nationally-owned development strategies supported by integrated national financing frameworks.

USAID’s partnership with the GOI clearly reflects this global movement of championing local solutions and country ownership. The Third International Conference on Financing for Development in July 2015 issued the Addis Ababa Action Agenda that outlines this same paradigm for sustainable development. It calls for much greater domestic resource mobilization supported by strengthened enabling environments in such areas as rule of law and civil society.

The global movement “Every Woman Every Child (2010)” led to this consensus and provided a roadmap for how to enhance financing, strengthen policy, and improve services on the ground for the most vulnerable women and children. The “Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030),” led by the WHO, also embraces the SDG model of building resilient and healthy societies. The confluence of several global development agendas offers Indonesia a unique opportunity to build a robust approach for reducing maternal and newborn mortality.

3) DOING MNH DIFFERENTLY

Given that past interventions have not led to a substantial reduction in maternal and neonatal mortality in Indonesia, USAID is open to new approaches. This coincides with several fortuitous dynamics underway in Indonesia.

Political and Structural Reforms are coming to Fruition.

Three seminal events have impacted health care provision in Indonesia. The first was the 1998 financial crisis, which triggered the end of President Suharto’s regime and issued in the reform era. The second was the 1999 devolution of authority to the districts and provinces and the beginning of decentralization, a process that continues to undergo refinement, most recently with the revised Law 23 in 2014 and the new village law, Law 6/2014. The third was the January 1, 2014 implementation of Universal Health Coverage (UHC), which currently provides coverage to almost 160 million people, of whom almost 88 million have subsidized premium payments from the government, under the single payer social health insurance program (Jaminan Kesehatan Natsional - JKN). The government has pledged to cover all its expected 275 million citizens by 2019. These reforms together have the power to transform the Indonesian health sector by allowing local governments to make locally-appropriate decisions on how to allocate their resources, thereby unleashing the power of strategic purchasing and dramatically increasing efficiency of resource allocation.

Potential for Private Sector Growth Presents a New Opportunity for Leveraging.

Indonesia’s GDP growth, fueled by both domestic growth as well as foreign direct investment has created an environment in which investors are searching for profitable ideas and established businesses are seeking to expand. In both cases, there is a significant interest in reaching the base-of-the-pyramid (the poorest 40 percent). Although JKN significantly improves the prospects of sustainable health financing in Indonesia, infrastructure investments to improve physical access to health care have not kept pace with growing demand. Indonesia only had 0.9 hospital beds and 0.2 physicians per 1,000 people in 201217. Furthermore, while 46 percent of pregnant women in Indonesia deliver at a private health facility, and 72 percent of the population access modern family planning methods from the private sector, JKN currently has limited private provider participation. As the UHC program reduces financial barriers and the population previously not accessing services starts accessing health care, engagement of the private sector will become critical to ensure that the health system is able to equitably respond to the needs of the entire population with high quality services. This crucial contribution of the private sector in the expanding Indonesian health system has been recognized and accepted by the GOI.

Opportunities for Civic Engagement have increased over the Last Decade.

Maternal mortality remains stubbornly high and neonatal mortality now accounts for almost 50 percent of under-five deaths. Interestingly, there has not been a significant public outcry against

17 The World Bank. World Development Indicators: Health Systems. http://wdi.worldbank.org/table/2.15. Accessed October 19, 2015.

the sector’s inability to effectively lower maternal mortality. This highlights the current country context in which local civil society organizations (CSOs) are not effectively engaged to ensure governance and accountability or as partners to effect change. However, the last decade has seen strong development of civil society and participation in public health has been growing18. The World Bank’s Worldwide Governance Index places Indonesia’s Voice and Accountability score at 52 percent, progressively increasing from 40 percent in 2004.19

Domestic and International Political Forces are Highly Aligned.

There is strong political commitment from the GOI for improving population health. Increasing budget allocation to the health sector, the launch of the JKN program, as well as a renewed emphasis on strengthening primary health care, specifically for reproductive and child health, through the MOH’s Kampung Sehat (Healthy Village) and Nusantara Sehat (Healthy Archipelago) programs, clearly demonstrates this commitment. Indonesia’s embrace of key global initiatives such as “Every Woman, Every Child”; “Ending Preventable Child and Maternal Deaths”; and the newly launched “Global Strategy for Women’s, Children’s and Adolescent’s Health 2016-2030”, also offer further opportunities to build a multi-pronged approach for tackling maternal and neonatal mortality.

USAID is poised to Shift its Development Strategy.

The increasing availability of public and private financing, autonomy at the provincial and district/municipality levels, thriving private sector, and improvements in political space for civic participation are all opportunities that can be leveraged. USAID’s funding envelope of US$20 million/year (FY15 Indonesia MCH appropriation), compared to the national health budget of over US$7 billion/year, represents 0.002 percent of total resources. Therefore, it is essential that USAID and its partners focus on leveraging local solutions and financial resources from public and private sectors to have maximal impact. Additionally, given the Indonesian government’s strong political commitment, coupled with interest by private finance, private business, and civil society to engage in the health sector, USAID should focus on catalyzing these groups to generate innovations that improve MNH, particularly targeting the poorest and most vulnerable.

Solutions created with the active participation of local interested parties from the earliest stages of program development are more likely to succeed and be sustained.

USAID Indonesia is shifting its development strategy to respond to the dynamic health system in Indonesia. We must do MNH programming differently by:

18 Evolution and Challenges of Civil Society Organizations in Promoting Democratization in Indonesia, Ministry of Disadvantaged Regions, presentation of March 2014, Yemen CSO Conference 19 The World Bank. Worldwide Governance Indicators.

http://info.worldbank.org/governance/wgi/index.aspx#reports. Accessed October 19, 2015.

● Engaging local stakeholders in developing solutions and fostering ownership;

● Emphasizing a total market approach for solution development;

● Co-financing and catalyzing increased investment in systemic innovation ideas;

● Co-creating and implementing systemic innovations; and

● Acting as a partner, facilitator and enabler.

Shifting ownership of problem solving entails sourcing innovative ideas from local stakeholders through a whole-of-market approach, i.e., establishing partnerships with motivated stakeholders across the public sector (district/municipality, province and national), private sector (service providers, financial institutions and other services like transport, telecommunications, etc.), academia, and civil society, including mainstream media, to help address MNH issues. The total market approach will seek the engagement of motivated existing and new players to develop, monitor, implement and spread politically and technically viable solutions and financial investment. USAID’s role will shift from funding implementation toward partnering, facilitating evidence creation, and promoting evidence dissemination. The aim is to assess improvements in specific technical focus areas contributing to the reduction in MN mortality, as well as health system efficiency, effectiveness and resilience in meeting existing and emerging MNH needs specifically, and population health needs in general.

4) CORE OPERATING PRINCIPLES

The following core operating principles will guide USAID’s investments under this activity. The Implementer must consider and incorporate all of the following principles into activity implementation:

Influence systems operating at scale to improve quality and access to essential, evidence-based, life-saving maternal and newborn health services by providing strategically placed technical inputs;

Provide catalytic support for system improvements by providing critical information and evidence to inform program and policy decisions at all levels, and support processes that facilitate the use of the best information and evidence in program and policy decisions;

Support an innovation ecosystem that fosters the development of creative programmatic and operational approaches, technologies and interventions, or information systems in order to break through barriers to progress, generating sound evidence to support sustainability and scale of innovations;

Adopt a total market approach - in which all sectors, public, private (for profit and not for profit), CSOs, and media work together to create solutions, approaches, and partnerships to deliver health care for all population segments, in particular the poorest most vulnerable;

Aim and evaluate all support for the extent to which it benefits the poorest and most vulnerable; and

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

5) THE APPROACH

Guided by the above mentioned principles, USAID will fund a 5-year activity that is flexible and adaptable in a way that can respond to MNH needs in Indonesia. This activity will leverage the power of the market to implement sustainable and scalable approaches to ensure MN survival, specifically among the poorest and most vulnerable populations in 10 focus provinces. The activity will implement a process to enable the identification, adoption, and spread of promising solutions and innovations through existing and leveraged domestic financing; provide innovators with catalytic funding, technical assistance, opportunities for partnerships, information, and/or other support, aimed at facilitating their ability to achieve sustainable impact at scale.

This will be achieved through the facilitation of an open innovation and partnership process20 that engages the full range of stakeholders (government, private sector, CSOs, academia and media). The process will first define and prioritize MNH issues in Indonesia, based on the best available evidence, and then catalyze the most promising solutions. The most promising solutions will be developed, implemented, and evaluated through strategic technical assistance and/or funding, as well as monitoring and evaluation support. It will also leverage local commitment, expertise, and investments.

The overall approach will have three management components (Management, Measurement and Communication; Innovation Fund; and Technical Assistance) and operate in at least six technical focus areas (Quality of Care in Public and Private Sectors; Referral System; Defining and Reaching the Poorest and Most Vulnerable; Local Governance; Financial Protection; and Evidence Utilization) described in further detail in subsequent sections.

The approach will support systemic changes necessary to achieve reductions in MN mortality at the national level. The Management, Measurement and Communication component will be the hub of this activity, supporting participatory problem definition and prioritization, managing the open innovation process, identifying technical assistance and funding needs, developing and implementing appropriate monitoring and evaluation (M&E) systems, and disseminating and advocating for system changes to help ensure adoption of successful innovations and other evidence-based approaches, while developing and implementing a process to continually update

20 https://www.usaid.gov/GlobalDevLab/about and refine knowledge of MNH priorities. The Innovation Fund and Technical Assistance components will be deployed to support the development, testing, implementation and monitoring of solutions identified through the open innovation process mentioned above.

The approach will result in solutions developed and implemented within and across each technical focus area. A key assumption of the design is that the market will respond with adequate quantity, quality and diversity of solutions that will result in significant improvements in chosen areas of technical focus, thus leading to desirable outcomes in MNH. Furthermore, the underlying hypothesis is that when taken as a whole these solutions will sufficiently influence the determinants of MN mortality, so as to catalyze adoption at scale.

Figure 7 is an illustration of the relative size, in terms of level of effort (LOE), for each management component. The Implementer must recognize that Component 1 will require the largest LOE followed by Component 2 and then Component 3. The Implementer must propose LOE distribution accordingly.

Technical Focus Areas

Based on a recent review of the drivers of MN mortality, and recognizing a broad range of determinants and influences on MNH, USAID has currently identified six technical focus areas (Table 2) that contribute to improving MNH outcomes, and consequently lead to reductions in mortality.

Table 2: Activity Technical Focus Areas and Expected Results

Technical Areas Expected Results

Technical Area 1 Quality of care in Improved quality of care in public and private

Innovation Fund

Management, Measurement & Communication

Technical Assistance

Figure 7 public and private sectors sectors

Technical Area 2 Referral system Improved referral system at community and facility levels

Technical Area 3 Defining and reaching the poorest and most vulnerable

Increased utilization of MNH services by the poorest & most vulnerable

Technical Area 4 Local governance Improved local governance systems

Technical Area 5 Financial protection Improved financial protection

Technical Area 6 Evidence utilization Improved utilization of evidence for decision-making in the public and private sectors

In order to identify priorities for innovation to reduce MN mortality, and to initiate a process of working with a broad group of stakeholders, USAID is supporting a process to gather and review all existing technical evidence related to MN health in Indonesia, and to identify issues and priorities on the critical path to accelerate reductions in MN mortality (Annex 2). This activity will build on USAID global experience with Evidence Summits,2122 and will adapt that process to best suit Indonesia’s specific needs.

Objectives include:

Acquire all existing evidence relevant to the determinants of maternal and neonatal mortality, implementation approaches…