IMPROVING URBAN HEALTH IN ASIA
ISSUANCE DATE: February 1, 2017 (5:00 PM EST)
CLOSING DATE FOR QUESTIONS: February 24, 2017
CLOSING DATE OF EXPRESSIONS OF INTEREST (EOI): March 24, 2017 (5:00 PM EST)
e-mail: AsiaUrbanHealthBAA@usaid.gov.
THE UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT
BUREAU FOR ASIA BROAD AGENCY ANNOUNCEMENT (BAA) NO. BAA-OAA-RM-2017
HARNESSING LOCAL INNOVATIONS, EXPERTISE, AND PARTNERSHIP TO SOLVE DEVELOPMENT CHALLENGES IN ASIA
ADDENDUM 01 - IMPROVING URBAN HEALTH IN ASIA
I. BACKGROUND
A. Overview
Achieving meaningful health outcomes in the growing number of urban centers of Asia requires an accurate understanding of the outcomes that matter to all segments of the urban population. This cannot be achieved without leadership and investment from local government institutions, civil society organizations and the private sector, nor can these outcomes be sustained over the long term without this local buy-in. Urban health, in particular, also requires collaboration far beyond the health sector to achieve lasting health and well-being.
Asia's dynamism and development trajectory demands a shift in thinking beyond traditional development programming. Change agents-ranging from conventional thinkers to disruptive innovators-abound in Asia, providing partnership opportunities that can speed the development curve for health. We seek to partner with these change agents to catalyze new ways to solve problems in urban health.
B. Problem Statement
With approximately half of the world's population living in Asia, mixed health systems are grappling with the shifting demographics of a rapidly aging population and overwhelmed with responding to the double burden of communicable and non-communicable diseases (NCDs). Urbanization further complicates health systems' ability to address these shifting health challenges. Home to 53 per cent of the world's urban population , Asia's urban growth continues to mushroom. In 2015, Asia's urban areas housed 2.11 billion people and are expected to further expand by 2020. While urbanization offers opportunities for economic growth as well as for the provision of better health and social services to the majority, it also creates a new range of challenges including growing inequalities between the well-off and the urban poor, particularly those living in slums who constitute more than one third of the urban population in Asia.
Rural-to-urban migration and natural population growth is rapidly increasing both city size and urban population size, impacting public health in complex, intertwined ways. The design of physical spaces and the built environment itself has impacts on personal health. Environmental quality in urban areas-air pollution, inadequate water and sanitation, substandard waste removal, poor construction and ventilation, chemical biohazards-also increase the spread of disease, communicable and non-communicable alike. The increased mobility between cities and rural areas, as well as overcrowding in many urban populations creates pathways for new sets of health challenges. In addition to migration from rural areas to very large cities that tend to capture most of the migratory flux, a new urban environment is being created with a rapid transformation of rural or peri-urban zones into second tier cities, which creates additional unique challenges.
Such massive migration and uncontrolled population growth not only challenges health systems, but exacerbates inequities for healthcare delivery, especially among highly mobile or undocumented urban poor. Increasingly, urban slums are seeing the convergence of communicable and non-communicable diseases : Infectious diseases are widespread in urban slum settlements , while NCDs disproportionately affect low socioeconomic groups that have the least access to and ability to utilize health care services and often are not protected by existing healthcare schemes, policies, and regulations. With urbanization as an underlying risk factor for NCDs, the urban poor are therefore caught in a cycle of poverty and poor health.
Several proximal and distal determinants, including employment/unemployment, workplace practices, race, ethnicity, gender and socio-economic status play a large role in determining access to quality healthcare in urban environments as well as habitat, urban infrastructures, security, waste management, and access to water and sanitation. These factors can be deeply rooted, vary greatly within a particular city, and play a large role in determining access to social services as well as the types and frequency of illness and health outcomes in different population segments. While cities offer a wide range of public and private providers, the slum population is often excluded and left with inadequate health care provided by unskilled, unlicensed, and unregulated providers. How, then, will health systems have to adjust to adequately meet the health needs of all urban dwellers in an equitable way?
C. The Asian Advantage
Fortunately, opportunities in Asia abound to propel health and other system responses to these challenges. An increasing number of high-tech health products and services are sufficiently low cost to enter and reshape markets. Mobile technology has the potential to revolutionize healthcare information systems globally. Strategic health governance strategies can tap into significant private health care markets to expand access to care and ensure greater equity within services. Continued general economic growth across Asia provides the opportunity to take advantage of domestic resources for health . Generally, Asian countries have a robust, although poorly regulated or unregulated, private health sector (for-profit and nonprofit), therefore public purchasing of private health care services can address inequities in access to services but quality is uneven.
This context lends itself to testing innovative approaches to improve the urban ecosystem in a way that will not only sustain good health outcomes for today's most pressing diseases over the long term, but can ensure responsive health care services as epidemiology and populations change over time. New approaches require bold ambition and the willingness to take risks with health care processes, but not with clinical outcomes .
D. Background: USAID's Health Priorities in Asia
Four main themes guide the Asia Bureau/Health Team's work:
1) Development programming that builds resilient and responsive health systems while maximizing sustainable impact on system performance and population health outcomes; this supports the larger agency goal of reducing poverty and managing maternal mortality, child health, and infectious disease threats.
2) Harnessing the evidence base to better understand sustainable solutions to health system challenges;
3) Enabling information sharing across Asia by building the institutional capacity of regional networks; and
4) Exploring intersections with other technical areas and partnering with the private sector to maximize potential for impact.
Within the above areas of emphasis, the USAID/Asia Bureau Health Team focuses on the following areas of work, in alignment with the UN Sustainable Development Goals 3 and 11 and the USAID/Global Health Bureau's goals .
Universal Health Coverage and Health Systems Strengthening (HSS)
USAID's Vision for HSS is to partner with countries to provide sustained, equitable access to essential, high-quality health services that are responsive to people's needs without financial hardship, thereby protecting poor and underserved people from illness, death, and extreme poverty. Its purpose is to guide USAID's work and investment focus to evidence-based HSS approaches that contribute to positive health outcomes and to foster an environment conducive to universal health coverage.
Many countries in Asia and the Pacific have committed, or are planning to commit, to delivering universal health coverage to their populations through their health systems, which are mixed (i.e. public and private sector delivery operates side by side) and the strength of these systems vary widely across lower and lower-middle income countries. Often the financing, supply, and policy elements of developing Asian health systems are not optimally regulated. Non-public providers, including informal, unregulated, and unskilled providers (such as unlicensed pharmacists) are operating outside of the formal health system and make up a large proportion of primary care providers that are often utilized by the urban poor, resulting in inequitable access to essential, high-quality health services and safe medical products.
With significant out-of-pocket expenditures for health and inadequate financial protection schemes, many governments have passed laws to establish national health insurance systems and have developed health financing strategies. The move toward Universal Health Coverage (UHC), including access for all and financial protection, is proving to be challenging. Poor and disadvantaged populations often are not covered by these schemes, and protecting the poor is not usually prioritized while most of the investments are in fact expanding the formal private sector.
Maternal, Newborn, and Child Health, and Family Planning
● Asia and the Pacific account for more than 41 percent of under-five deaths in the world, more than 44 percent of maternal deaths, more than 56 percent of newborn deaths, and approximately 60 percent of stunted rates for children under five.
● There are still large disparities between the lowest and highest wealth quintiles in vaccine coverage in countries such as India, Indonesia, and Vietnam or within a geographic area such as Cambodia and Myanmar in the Mekong.
● Fifty-five percent of all people globally who require family planning services but do not have effective access to them live in Asia and the Pacific.
● Despite regional economic growth, many women living in urban areas have no access to skilled providers. Only 41 percent of expectant mothers in South Asia have a skilled birth attendant present during deliveries- one of the lowest rates in the world.There are huge disparities in access to antenatal care and skilled birth attendance.
● Compared to Africa, rates of facility delivery are lower in Asia and a greater proportion of deliveries are in private facilities. In Asia, living in an urban area, being in a higher wealth quintile, and living in a non-male household head were significantly associated with increased odds of delivering in a facility.
Nutrition and Sanitation
● Asia is home to 62 percent of world's undernourished children. Among the top 30 countries globally for moderate to severe stunting, seven countries are in Asia: Cambodia, India, Laos, Nepal, Papua New Guinea, and Timor Leste.
● At the same time a dual burden of malnutrition is emerging, combining under-nutrition and overweight and obesity among mothers and children. This often leads to hypertension, which may cause pregnancy complications, such as pre-eclampsia and complicated deliveries, resulting in worse health outcomes for both mother and baby.
● The number of overweight children is increasing most rapidly in Asia.
● Over- and under-nutrition alike have distinct effects on risk of TB infection: Diabetes enhances the risk of pulmonary TB, but a greater body mass index (BMI) is protective against TB -- yet diabetes is more frequent among people who are overweight. Low BMI is also a risk factor for TB infection.
● Approximately 1.7 billion people in Asia have no access to sanitation-an increasing problem for urban areas where communities grounded on poor infrastructure are on the rise. An average of 780 million people in the region have limited or no access to safe drinking water, and urban populations, particularly those living in slums share environmental risks, experiencing so-called neighbourhood effect. Many still practice open defecation and 80% of wastewater is discharged with little or no treatment, resulting in diarrheal disease, malnutrition, and pollution. In fact slum dwellers perceive water and sanitation as their most pressing need.
Infectious Diseases
The high concentration of people living and interacting with others in urban places can increase the risk and rate of disease transmission. The ability of urban centers (through local or devolved national government action) to respond to rapid increases or high incidence of infectious disease is critical to improving health outcomes in a more urbanized Asia.
HIV
● The Asia region is home to the largest number of people living with HIV outside of sub-Saharan Africa. There are approximately 5 million people living with HIV- 340,000 new cases per year in the region, and only 1.9 million currently on treatment, which lags behind global trends.
● Though countries in Asia have made tremendous progress in tackling the HIV epidemic, HIV remains a key issue within specific populations. The epidemic in these countries is concentrated among key populations: drug injecting users, sex workers, and men who have sex with men.
Tuberculosis
● Nine of the world's 22 high burden tuberculosis countries, which together account for more than 80 percent of the world's TB cases, are in Asia and include: Bangladesh, Myanmar, Cambodia, China, India, Indonesia, the Philippines, Thailand and Vietnam. In 2014, the largest number of new TB cases occurred in the South-East Asia and Western Pacific Regions, accounting for 58 percent of new cases globally.
Malaria:
● Despite many public health advancements in the region, 65 million people in Southeast Asia are at risk of malaria infection. An estimated 260,000 people are infected with malaria each year in the Greater Mekong Sub-region. The true number, however, is likely much higher because of poor detection and reporting in rural areas where the disease is common.
● Artemisinin resistance has been confirmed in five countries of the Greater Mekong sub-region: Cambodia, Laos, Myanmar, Thailand and Vietnam. The majority of patients with artemisinin-resistant parasites still recover after treatment, provided that they are treated with an effective artemisinin-based combination therapy; however, the market for counterfeit and substandard drugs will continue to impede development efforts to reduce morbidity and mortality if unaddressed.
Emerging Infectious Diseases:
● Emerging infectious diseases of pandemic potential, such as influenza viruses of animal origin and the Middle East Respiratory Syndrome Coronavirus (MERS-CoV), remain persistent threats to livelihoods, food security and health across Asia. The economic cost of the 2003 SARS epidemics is estimated at US$ 54 Billion by the World Bank. The emergence of avian influenza A/H7N9 in China underscores the dynamic nature of such threats, and the importance of prompt, evidence-based control of emerging diseases at their source in order to mitigate negative regional and global public health impacts.
● There is no denying the staggering financial implications of pandemics: if an outbreak is not rapidly controlled, it could result in major losses of livelihoods affecting both rural and ruban communities; a projected reduction in global trade by 14 percent; and cause economic losses in Asia worth $263 billion, a 5% loss of the global GDP. Pandemics also shock a health system, with immediate stressors on the health workforce to rapidly mobilize and continue to provide essential, routine services as well as those that directly address the infectious disease outbreak.
● The vulnerability of Asia to climate change, with consequences such as the destruction of land and habitat, food production, and increased mortality risks due to disaster such as earthquakes, floods and tropical cyclones increase physical barriers to healthcare access. With long-term effects such as land erosion, an increase in migration to urban areas will result in an increased demand for urban health services. Climate change also changes the epidemiology of communicable diseases, such as the distribution of mosquito vectors which changes the patterns of transmission of diseases such as malaria, dengue fever and more recently the Zika virus. This will also burden an already weak health system that is not prepared to respond these types of shocks.
Non-Communicable Diseases (NCDs)
NCDs are the leading cause of premature death and disability in all regions of the world except Africa, where they are expected to be the leading cause by 2030 and they are one of the major challenges for development in the twenty-first century. The top NCD killers in the Southeast Asia and Asia Pacific regions are cardiovascular disease, chronic respiratory disease, diabetes and cancer. In the Asia Pacific region, 62 percent of annual deaths in the South East Asia region are due to NCDs in the South East Asia region while 75 percent of deaths in the Western Pacific region are due to NCDs. The WHO estimated that the highest worldwide increment in total mortality in a 10-year time frame (2005-2015) will be observed in the South-East Asia and Western Pacific regions with 21 percent increase in the South-East Asia region and 12.3 million deaths in the Western Pacific region. 48 percent of deaths due to NCDs in South East Asia occur before the age of 70 years, thus largely affecting economically productive individuals. Furthermore, smoking, second-hand smoke, obesity, and diabetes during pregnancy are linked to preeclampsia, spontaneous abortion, stillbirth, congenital anomalies, macrosomia, obstructed labour, and the need for caesarean delivery.
Increases in NCDs are due to in large part to ageing populations, urban development planning and growth, climate change and the lack of readiness of health systems and other systems to address NCDs. High out-of-pocket payments to care for and treat NCDs push people into poverty. Countries moving towards UHC aim to provide financial health protection and access to NCD services, including early diagnosis, treatment, and palliative care. There will be an increased demand for patient-centered care and as countries develop their benefit packages, they will need to decide which NCD services they can cover for their populations and how they can pay for them. Countries will need to ensure that their pharmaceutical systems and the health workforce are efficiently and effectively ensuring that NCD related commodities and services are high quality, available, and accessible to all, especially the poor, underserved and vulnerable populations. While the behavioral risk factors that contribute to NCDs are tobacco use, unhealthy diet, insufficient physical activity and harmful use of alcohol, which are more prevalent in urban areas, NCDs are largely preventable and cost-effective interventions are available.
II. OBJECTIVE & AREAS OF INTEREST
A. Objective
This Addendum seeks, through co-creation with local partners, systems approaches to overcoming urban health challenges in Asia.
The Addendum should support one or more of USAID's health goals as outlined in Section I and pursue solutions that improve Asian urban cities'/municipalities' ability to equitably improve health outcomes.
B. Areas of Interest
While growth in megacities and primary cities will continue, growth in secondary cities will occur more rapidly, in more places, and place more strain on the infrastructure and governance to adapt. As available space is already limited in large and mega-cities, secondary cities will likely rapidly become home to the majority of a country's urban residents. These cities will require more attention to adequately plan and deploy of resources since their low capacity to address the needs of urban dwellers is insufficient. These secondary cities typically have weaker governance and a lower ability to access resources than primary cities, which will contribute to a range of public health associated needs. As such, the geographic focus of this Addendum focuses on any city of 750,000 to five million population with a recent annual population growth rate of three percent or more in Cambodia, India, Indonesia, Laos, and Vietnam.
The Addendum will support targeted approaches for shaping functioning models of resilient and equitable health systems in urban settings.
Health and other systems in Asia's rapidly urbanizing cities must increasingly respond to shocks-be they natural disasters, economic crises, acts of terrorism, food insecurity or infectious disease outbreaks-while at the same time, evolve to address a multitude of transitions that impact health and be designed to address the dual burden of diseases due to the aging population. As such, this Addendum will focus on new approaches and models that will contribute to resilient, equitable urban health systems that can deliver quality health services and improve health outcomes for all members of the urban population.
Rather than embarking on comprehensive urban health systems reform, we are interested in targeted interventions that test different approaches to optimize a health element of a city's existing health system. What nudges does any one piece of the health system need to operate more efficiently and effectively? For example:
● What tools or processes work best to support an urban health system that is resilient to external shocks and overcomes barriers to utilization such as distance and cost
● What are effective models of how philanthropy, social entrepreneurialism, and/or corporate social responsibility improve access to quality health services and contribute to the creation of and effective, equitable and resilient health system in urban areas?
● What are the most cost-effective ways of reaching urban slum-dwellers with essential health services provided by qualified providers, which are affordable? This is needed to mitigate the risk of being pushed into poverty due to the cost of catastrophic illness, which may affect all wealth quintiles.
● What are some effective ways of integrating NCD detection, prevention, and management into primary health care services while maintaining communicable disease detection, treatment, and prevention efforts at the primary care level?
● What innovations in management, recordkeeping, health information systems, disease surveillance, or service delivery that improve health outcomes have the greatest potential to be sustainable so as to ensure integration into the country's urban health system?
● What successful approaches and policies can be used to improve cross-sectoral planning, governance, and synergies among health, sanitation, urban planning, environmental, and other directorates beyond health to maximize the investments-and potential outcomes-of all sectors?
● What can be done to improve disease surveillance systems?
● How to improve health information systems that will allow disaggregation of information by economic status and differentiate between slum-non slum populations?
● What are effective models of engaging with unregulated, untrained health care providers in urban settings so that slum-dwellers can get quality care?
● What are ways to engage urban communities in local health planning, oversight of the provision of care, and to improve the accountability of all providers?
This illustrative list is not exhaustive by any means. It is meant to give offerors a sense of the scale of approaches we are interested in testing and the level of investment for those approaches.
III. INSTRUCTIONS FOR SUBMITTING EXPRESSIONS OF INTEREST
USAID Asia Bureau, Global Health Bureau, and health office staff in the Cambodia, Indonesia, India, Laos, and Vietnam Missions will review Expressions of Interest (EOI) in accordance with the instructions and evaluation criteria set forth in this Addendum.
EOIs must indicate the development approach(es) that will deliver potential solutions to the Objective stated in Section II. Organizations are encouraged to collaborate with peer organizations that bring differing perspectives and/or comparative advantages. Organizations are also encouraged to think through innovative cost-sharing arrangements. USAID is supportive of approaches that value collaboration as a component of the co-creation and co-resourcing process.
USAID will accept up to two EOIs from a single organization.
A. General Instructions for the EOI
EOIs must be submitted in accordance with the following:
1. If a respondent does not follow the instructions set forth herein, the respondent's EOI may be eliminated from further consideration.
2. USAID will not pay for any EOI preparation costs.
3. EOIs must be submitted in English.
4. All EOIs submitted in response to this Addendum are due no later than the closing date and time indicated in this Addendum.
5. EOIs submitted in response to this Addendum will be received by electronic submission only. Facsimile or hardcopy submissions will not be accepted.
6. EOIs must be emailed to AsiaUrbanHealthBAA@usaid.gov.
7. The EOI must not exceed four (4) pages in length. EOIs longer than four (4) pages will not be considered.
8. Respondents must use 8.5 by 11 inch (or A4) paper, single spaced, Times New Roman 12 point font, and have margins no less than one inch on the top, bottom, and both sides. Number each page consecutively.
9. The EOI must be in .pdf and word versionst
10. The EOI must contain a cover page with the following information:
• Title: BAA for HARNESSING LOCAL INNOVATIONS, EXPERTISE, AND
PARTNERSHIPS TO SOLVE DEVELOPMENT CHALLENGES IN ASIA
● BAA Number: BAA-OAA-RM-2017
● Addendum No.: 1
● Name of the respondent:
● Respondent contact person, address, telephone number, and email address
11. Questions in regard to the BAA must be submitted via email only to the AsiaUrbanHealthBAA@usaid.gov. Questions must be submitted by February 24, 2017 at 5:00 PM Eastern Standard Time.
EOIs must be submitted by March 24, 2017 at 5:00 PM Eastern Standard Time. The subject line of the email must contain "BAA-OAA-RM-2017/Addendum No. 1" and the name of the respondent.
B. Content of the EOI
1. Provide a brief description of your idea/approach as it applies to Section II of this Addendum. Be sure to address:
a. How your idea will improve a facet of urban health in Asia, as it applies to one or more of the Areas of Interest found in Section II.
b. How does the proposed approach have potential to be a cost-effective, scalable, and sustainable endeavor?
c. How you might implement your idea or approach?
d. How you will undertake implementation research to answer questions of feasibility, acceptability, scalability and/or costs?
e. What you could gain from the co-creation process in terms of partnerships that would continue to build upon your idea/approach.
2. Provide a brief description of your organization's experience or expertise in the idea/approach you are proposing. Address your ability to harness the comparative advantages of other parties and collaborate with other actors, including city and local governance structures. Please indicate specific relationships with private sector actors, and pre-existing partnership commitments to address urban health.
3. Provide the approximate duration and target location(s) of your proposed idea/approach. Note that the EOI should identify the proposed target cities within the EOI.
4. Provide names of up to two (2) individuals nominated to participate in the Concept Paper workshop, as described in this Addendum. Describe why the individuals you are nominating are the best people to co-create promising approaches to urban health alongside USAID staff and other organizations. Note: Individuals whose focus is on business development for the respondent organization will not be considered for participation in the workshop. USAID reserves the right to disapprove nominated individuals and request additional/different nominations at its discretion.
IV. EVALUATION CRITERIA
EOIs will be reviewed and selected for Stage 2 of the BAA process according to the following Evaluation Criteria:
Idea/Approach
A. How does the proposed idea/approach introduce an innovative approach, fresh perspective, and/or non-traditional solution for urban health systems?
B. Is the proposed idea/approach technically sound and grounded in evidence?
C. Does the proposed idea/approach demonstrate the potential for impact and can progress towards this impact be measured over time?
D. Does the applicant describe a practicable approach to conducting high quality implementation research?
Partnership Expectations and Values
D. Strengths your organization would bring as a partner, including your ability to make unique contributions to urban health systems and local context expertise.
E. Experience of your organization in building unique partnerships, including with private sector actors to address urban health challenges.
F. Diversity of perspectives and capabilities your organization would bring to the table to enable broader thinking and innovation.
Cost considerations/Co-financing
G. How does the proposed idea/approach include ideas for additional financing/cost-sharing?
H. Does the proposed approach have potential to be a cost-effective, scalable, and sustainable endeavor?
Ability to Participate
I. Does the respondent have the ability to provide the participation of up to two (2) technically experienced individuals in the co-creation workshop. Note: It is essential that the participants nominated will be able to participate in the workshop full time. USAID will not pay for travel costs for participants.
Diversity of Perspectives and Capabilities
J. USAID seeks to bring together a diverse set of co-creators and resource partners to enable broader thinking, innovation, a shared vision, and a larger resource pool for the region. In particular, we are interested in tapping into local expertise, perspectives, solutions, and financing to improve health outcomes over the long term. Co-creators must have experience within the past five years of working with urban populations. The selection of EOIs will be in line with the goal of achieving this diversity.
V. SPECIAL INSTRUCTIONS FOR PARTICIPATION
For EOIs that are deemed by USAID to have merit to continue on to the Concept Paper stage under this Addendum (Stage 2, per the BAA), USAID will issue an invitation to collaborate to the potential partner(s). Collaboration will entail:
1. Working together, USAID and the potential partner(s) will collaborate on a Concept Paper(s). It is during this phase of co-creation or co-design that the parties will begin to determine the need for additional partners and resources to complement the project. The Concept Paper, generally 5-10 pages in length, will further detail and explain the project as initially described in the EOI. The Concept Paper will include concept notes, which will outline a concrete programmatic plan, including goals, methodology, focus areas, monitoring and evaluation, sustainability, gender considerations, timelines, personnel, and budget.
2. In order to initiate the Concept Paper drafting process, a three to four day co-creation workshop meeting is tentatively scheduled for the week of May 8 2017 in Bangkok, Thailand. The co-creation workshop will be held in English. USAID will make every effort to provide as much advance notice as possible regarding the confirmed workshop location and any change in the meeting dates, as well as further information with regard to the BAA process.
3. Movement forward to Stage 3 of the co-creation workshop is not guaranteed for all partners by virtue of making it to an earlier stage of the process.
ALL TERMS AND CONDITIONS SET FORTH IN THE BAA ARE APPLICABLE TO THIS ADDENDUM
[END OF ADDENDUM]
Benjamin Duodu, Contracting Officer, Phone 2025674799, Email bduodu@usaid.gov
