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CFAs: Health System Strengthening Flagship (Indonesia)

Deadline: 27-Sep-2024

The United States Agency for International Development (USAID) is seeking applications for a Cooperative Agreement from qualified entities to implement the Health System Strengthening (HSS) Flagship.

Goal and Objectives  
  • The overall goal is to improve the performance of the health system by strengthening the local institutional architecture within the financing, information system, and human resources functions of the system to be more accountable and resilient; and establish a pathway for MNH, TB, HIV, and GHS programming to provide equitable access to quality, affordable, essential health services; and sustain improvements in health outcomes.
  • The objectives are as follows:
    • Objective 1: Strengthen accountability and performance of health financing to sustain an effective and equitable health system
    • Objective 2: Advance the maturity of health information systems to provide reliable, usable data
    • Objective 3: Optimize the health workforce to efficiently and equitably deliver services
    • Objective 4: Design and organize more integrated, patient‐centered care models
    • Objective 5: Institutionalize mechanisms to support a routine, evidence‐informed health policy process
Funding Information
  • USAID intends to award one (1) cooperative agreement pursuant to this notice of funding opportunity. Subject to funding availability and at the discretion of the Agency, USAID intends to provide up to $35,000,000, including $8,000,000 for a window of opportunity, over a five (5) year period.
Result Framework
  • Objective 1
    • The financing objective focuses on two intermediate results as outlined below. The expected outcome from this work is a simplified, aligned, and more flexible approach to health‐related public financial management (PFM), providing a clearer link between financing and performance, clarified metrics and responsibility, and strategic purchasing under JKN. The relevance to the vertical programs will be the introduction of coherent local planning of vertical program activities, with accountability, and a pathway to more gender‐responsive, inclusive, sustainable and targeted financing and purchasing options for the vertical programs. The HSS Flagship will also be supporting operationalization and implementation of the new Omnibus Health Law (Law 17/2023) as it relates to the below Intermediate Results (IRs).
    • IR1.1: Optimize and rationalize public financial management at the subnational level 
      • The multiple flows of health financing in Indonesia have created complexities for financial planning at the national, district, and facility level, including lack of financial tracking and diversion of subnational funding away from health. The GOI is considering performance measures to determine future allocation levels to health facilities.
      • Illustrative Activities:
        • The HSS Flagship may consider the following illustrative interventions:
          • Improve financial resource tracking and clarify who pays for what.
          • Tie financial transfers to health performance metrics at the sub‐national level.
          • Align revenue streams for a coordinated, flexible, and rationalized local planning approach by using the vertical programs as tracers and test cases.
    • IR 1.2: Improve the purchasing and payment arrangement under JKN to improve TB, MNH, HIV services 
      • USAID’s previous Technical Assistance (TA) on strategic health purchasing (SHP) to Ministry of Health (MOH) and the Social Health Insurance Agency (BPJSK) under JKN focused on piloting Primary Health Care (PHC) provider payment models to incentivize public and private providers to improve MNH and TB services. The HSS Flagship will build on the strategic purchasing capacity and purchasing arrangement to improve quality and use of services at PHC level, while also intensifying the role of private providers in the health system.
      • Illustrative Activities: 
        • Provide TA to national and subnational level stakeholders to build strategic health purchasing capacity (SHP).
        • Explore the capacity and framework to contract with private or public facilities or organizations for specialized services (e.g., for HIV key population services or community based TB services).
        • Ensure that the needs of the vertical programs are included in the JKN benefit package, if necessary by exploring moving some optional issues into supplemental JKN benefit packages.
        • Provide TA to MOH and relevant counterparts to conduct financial modeling, costing analysis, and/or monitoring of JKN tariff implementation, including Inagrouper.
  • Objective 2
    • The health information system (HIS) focus is on ensuring the continuation of digital health transformation and building the data use culture to inform policy dialogue and decision making in alignment with the continuum of care and the data‐driven achievements of USAID priority vertical programs, including MNH, TB, HIV, and GHS. The HSS Flagship will continue strengthening the health information system platform under the MOH known as “SatuSehat” and the interoperability of disease information systems into the SatuSehat.
    • IR 2.1. Improve availability of real‐time high‐quality data and interoperability of the health information system 
      • Considerable progress has been made in articulating a digital health vision and in establishing the building blocks for this vision. However, the place of the vertical programs in this vision still requires clarification. The Flagship will roll out interoperability for information systems that is inclusive on gender and social issues, related to USAID vertical programs at national and subnational levels, document and measure the resulting savings in data entry burden, and assess where and how the resulting data can be visualized to drive more effective outcomes.
      • Illustrative Activities:
        • Clarify the MOH technical directorates’ and other GOI cross‐sectoral needs for data, information, data systems and dashboards, and support the development and adoption of a standardized data and interoperability approach for the vertical programs under the SatuSehat platform and GHS‐related information systems.
        • Enhance SatuSehat and Sistem Informasi Zoonosis dan Emerging Infectious Diseases (SIZE) function and implementation for surveillance, prevention, and response to improve health resilience at subnational and facility level.
        • Define solutions for the data needs under the other Flagship objectives, e.g., to support gatekeeping and reduce referral delays (linked with Objective 4) and/or for the implementation of performance‐based financing (linked with Objective 1).
    • IR 2.2 Promote culture of data use for decision‐making across all users of the health system 
      • With information systems in place, the Flagship will also strengthen the culture of using data to problem solve and take action, improve data analytics capacity of existing systems, and improve the ability of program managers at national and subnational levels, policy makers, HRH, and patients to make informed decisions which are gender responsive and inclusive to equally benefit everyone.
      • Illustrative Activities: 
        • Improve design and user experience of data analysis and its applications for all relevant user groups (e.g. GOI, practitioners, patients) both at national and subnational levels, with a particular focus on the needs of the vertical programs.
        • Provide TA to improve data use and decision tools, as well interactive digital tools to facilitate the exploration and use of data at national and subnational level.
  • Objective 3
    • The HSS Flagship will be the Mission’s first bilateral project that focuses on strengthening the management and planning of HRH for primary health care and public health functions across the public and private sectors. The HSS Flagship outlines a vision for a more organized and efficiently distributed healthcare workforce. This workforce would better support integrated, patient centered models of care by providing sufficient financial resources and staffing to meet workload demands.
    • IR 3.1 Improve management and planning of health workforce 
      • The HSS Flagship will identify the current barriers to optimizing the existing health workforce. This is a high priority, as the objective is to efficiently and effectively manage the workload of primary care, and public health and one health functions. The HSS Flagship aims to build a resilient health workforce and work environment that can effectively respond to future primary care and public health demands including those in rural and remote areas.
      • Illustrative Activities:
        • Provide TA to analyze the workload and staffing needs, assess the health labor market, and develop the capacity to develop HRH projection and planning models to address gaps in HRH distribution, including gender sensitive lens, across districts and facilities.
        • Expand human resource information systems to better track both formal and informal, as well as public and private HRH data to make management and planning modifications.
        • Collaborate with national and subnational stakeholders, including facilities, to improve HRH strategies (including for CHWs), policies, and enabling environment.
  • Objective 4 
    • To improve the integration of service delivery, the HSS Flagship will operate under the MOH’s and BPJSK’s priorities. It will work through horizontal integration across providers and vertical integration across levels of care whereby the management and delivery of health services results in a continuum of healthcare that meets patients’ needs. Currently USAID/Indonesia is testing integrated care models through the vertical programs to improve the effectiveness of program implementation.
    • IR 4.1 Advance integrated care mechanisms and the associated system requirements 
      • The HSS Flagship will further advance Indonesia’s integrated care models by designing, monitoring, piloting, and evaluating clinical and organizational mechanisms that incentivize better health outcomes impacting MNH, TB, HIV, and GHS. Clinical mechanisms may include horizontal clinical networks and multi‐specialty teams, defined referral protocols, expanding the scope of providers to provide more types of services, establishing care coordinators etc. Organizational mechanisms may include data interoperability, financial and health workforce management, providers vertical integration (e.g. co‐location or merger), intermediary organizations to support community care, etc.
      • Illustrative Activities: 
        • Map and assign providers’ roles in the networks, including formalizing their linkages, referrals, and accountabilities.
        • Design integrated care models including guidance, frameworks, and protocols (e.g. referrals) that formalize linkages and increase accountability across providers, with reference to the necessary financing, HRH, and information systems, ILP, and linkages to vertical programs and community‐based responses.
        • Design and implement a pilot of an integrated care model and conduct monitoring and evaluation to identify challenges and best practices and advocate for policy and regulatory improvements.
    • IR 4.2 Performance linked to quality of care and patient experience 
      • As the HSS Flagship Activity designs the integrated models to support more organized patient centered care, the providers must be held accountable ‐ specifically, linking their performance to the quality of care. This Activity will aim to leverage existing health facility quality assurance processes as an entry point, increase private provider participation, support the role of the network coordinator in improving the patient’s experience with the health system, and improve policies to allow payment arrangements that influence providers’ behavior.
      • Illustrative Activities: 
        • Institutionalize the process of ensuring facility readiness and quality, under District Health Office (DHO) or other Memorandum of Understandings (MOUs), specifically for MNH, TB, and HIV.
        • Explore an integrated supportive supervision tool that covers all priority programs and aligns with the ILP and team‐based care models.
  • Objective 5
    • As Indonesia is in the midst of implementing health transformation reforms, the capacity to continuously learn and innovate across the health system needs to be strengthened to ensure more effective, evidence‐informed health policies are implemented. It is expected that the other HSS Flagship objectives and other USAID activities will continuously be conducting research and/or supporting the production of evidence (i.e. evaluating existing policies, designing and testing new innovative models around purchasing or care delivery), which should be used to inform the health sector.
    • IR 5.1 Enhance the agenda setting and health policy formulation process to incorporate evidence 
      • The HSS Flagship will strengthen Indonesian institutions’ capacities to recommend innovations and translate research findings and analytical insights to serve as a foundation for evidence based policy making. In addition to capacity building support, this activity will explore and develop mechanisms to strengthen routine engagement between researchers and policy makers. While Indonesia constantly generates evidence, the HSS Flagship will empower think tanks, research institutions, universities, local partners, CSOs including those under‐represented groups, such as women and marginalized communities, etc. to extend their focus beyond academic and pilot dissemination.
      • Illustrative Activities: 
        • Strengthen health policy and systems research institutions capacity to support the implementation of health reforms on system performance and improvement of health outcomes.
        • Design new evidence to policy development pathways and provide support to local government and non‐government stakeholders across the evidence‐to‐policy system.
    • IR 5.2 Establish an enabling environment to institutionalize routine testing of innovations and policy evaluation 
      • The HSS Flagship Activity will establish an enabling environment for policy implementation to address the challenges around regulatory restrictions that hinder the process for testing innovations. Many countries that are working to achieve universal health coverage and implementing health sector reforms often implement flexible mechanisms to allow testing interventions under existing and/or special regulations, thereby fostering a more agile and responsive healthcare system. If the results of test intervention demonstrate success, this enabling policy environment should also support the full implementation and scale of the HSS intervention.
      • Illustrative Activities 
        • Introduce and institutionalize flexible, routine testing mechanisms, (e.g. regulatory sandbox models, innovation hubs/centers of excellence, learning labs at the district level) to support evidence genderation under the other HSS Flagship objectives.
        • Support policy evaluation and implementation research for selected policies that impact USAID vertical programs, which will be used as “tracers” for the overall process.
        • Improve national and local government performance implementing and monitoring policies, including mechanisms that support shared governance (when multiple institutions, ministries, and levels of government are all stakeholders) and client engagement and feedback that considers gender and social inclusion aspects.
Geographic Code
  • The geographic code for the procurement of commodities and services under this program is 937. Geographic code 937 is defined as the United States, the cooperating/recipient country, and developing countries other than advanced developing countries, and excluding prohibited sources. USAID maintains a list of developing countries, advanced developing countries, and prohibited sources, which is available in USAID’s Automated Directives System, ADS 310.
Eligibility Criteria
  • U.S. and non‐U.S. organizations from the authorized geographic code (937) may participate for this NOFO. USAID will not accept applications from individuals. All applications must be legally recognized organizations under applicable law.
  • Pursuant to Code of Federal Regulations (CFR) 2 CFR 200.400(g), it is USAID policy not to award profit under assistance instruments such as cooperative agreements. While for‐profit firms may participate, pursuant to 2 CFR 700.13(A)(1) Prohibition against profit: no funds will be paid as profit to any for‐profit entity receiving or administering Federal financial assistance as a recipient or subrecipient, and as such, for‐profit organizations must waive profits and/or fees to be eligible to submit an application.
  • Applicants are encouraged to form partnerships when developing Concept Paper. Please note, that Applicants can serve as sub‐awardees, members of a consortium or supporting partners on multiple Concept Paper. However, all eligible interested organizations are restricted to submitting only one Concept Paper as the Prime Applicant at any given time.
  • Successful applicants must have established financial management, monitoring and evaluation processes, internal control systems, and policies and procedures that comply with established U.S. Government standards, laws, and regulations.
  • USAID welcomes applications from organizations that have not previously received financial assistance from USAID.
  • Faith‐based organizations are eligible to apply for federal financial assistance on the same basis as any other organization and are subject to the protections and requirements of Federal law.

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