Institutional Capacity Assessment on Nutrition in Indonesia 1. Background and justification Malnutrition has serious consequences for the survival, health and well-being of millions of children in Indonesia, as well as economic development. The country has the fifth largest number of stunted children (almost 9 million) in the world, and the fourth largest number of children suffering from acute malnutrition (almost 3 million). Recent nutritional surveillance data of the Ministry of Health indicate a reduction in stunting, however, the levels of undernutrition remain unacceptably high. In addition, overnutrition is rising rapidly and is driving an alarming increase in non-communicable diseases. Indonesia s active engagement in the global Scaling Up Nutrition (SUN) Movement since 2011 has been instrumental in elevating the political prominence of malnutrition and in bringing multiple sectors and stakeholder groups together at the national level in a collaborative effort to address nutrition challenges. The SUN Movement is known as the Gerakan Nasional Percepatan Perbaikan Gizi Dalam Rangka 1000 Hari Pertama Kehidupan (Gerakan 1000 HPK). This multisector and multistakeholder Movement has struggled to gain momentum at the subnational level in Indonesia. Several analyses and assessments found that nutrition service delivery deteriorated in Indonesia followed the big bang implementation of decentralization in 2001. They point to the difficulties that provincial and district governments have faced in planning, financing and managing their new responsibilities under decentralization: An institutional analysis in 2006 1 identified five issues limiting Indonesia s response to nutrition problems. First, government structures, processes and staffing levels were unsuited to tackling nutrition problems; second, the overall skills level of district staff were low, particularly in programme planning and evaluation; third, the planning and implementation of nutrition programmes was inadequate; fourth, there were limited resources for nutrition programmes; and fifth, there was substantial variation in the collaboration with groups outside the government at district level. A landscape analysis on nutrition conducted in 2010 2 recommended that priority be given to creating mechanisms which promote the development of harmonized Food and Nutrition Action Plans at province and district level based on the national plan, regulations and guidelines, as well as to developing inter-sectoral coordination mechanisms to oversee and monitor their implementation. It explained that since decentralization there has been a shortage of nutrition capacity at the district level combined with the challenges to coordination and leadership at the provincial and central levels has resulted in a deterioration of nutrition programmes in general. A background paper of the Health Sector Review in 2014 3 found that opportunities to ensure policy and programme coherency on nutrition between sectors are being missed due to the lack of effective coordination structures for intersectoral and vertical coordination across all levels. It concluded that there are Weaknesses in the commitment and capacity to plan, implement, monitor and evaluate services, particularly at provincial and district levels. Within the health sector, the coverage and quality of almost all nutrition-specific interventions was low or unknown. There are four main administrative levels in Indonesia: national, province, district and sub-district. The country has 34 autonomous provinces and about 500 districts and municipalities. In 2014, a new law (UU 23/2014) was passed that redistributed functions across the various administrative levels responsible for service delivery, and gave greater authority to the central and provincial levels. At province and district level, the Planning Offices (Bappeda) coordinate across sectors to develop and monitor the implementation of short and medium term plans, including the five-year Province/District Medium Term Development Plans (RPJMD), the five-year Province/District Plans of Action on Food and Nutrition (RAD-PG), and annual plans.
Within the health sector, the central Ministry of Health (MoH) is responsible for the formulation of national legislation, policies, plans, and strategies on nutrition-specific interventions, and the development of guidelines to facilitate policy implementation. Province Health Offices (PHOs) are responsible for supporting districts to operationalize these national-level documents, and for the management of individual and public health efforts at province level and inter-district referral. District Health Offices (DHOs) have the primary responsibility for the management of individual and public health efforts at district level and for district/city referral. The public health system is underpinned by a network of over 9,000 community health centres (Puskesmas), each serving catchment areas of 25,000-30,000 individuals and a hospital system of 548 district, 98 provincial and 33 central hospitals. The Puskesmas implement services at sub-district level, and coordinate service delivery across a variety of lower-level structures including auxillary Puskesmas (known as Pustu) and village-level delivery posts (Polindes) and village-level health posts (Poskesdas). In addition, community-level participation is active in maternal and child health services, including promotion activities, at around 270,000 integrated community posts, known as Posyandu. These services include growth monitoring and promotion, twice-yearly vitamin A supplementation, deworming, and infant and young child feeding counselling. While the MoH is responsible for technical oversight of health services, the PHO and DHO are accountable to Governor and Bupati, respectively, under the Ministry of Home Affairs (MoH). To improve public services and address regional disparities in public service delivery the MoHA has introduced minimum service standards (SPM) for health and other sectors. There is concern among the nutrition community that districts may not give sufficient priority to the nutrition component of SPM. The Puskesmas are also responsible for delivery of community nutrition services through the Posyandu. However, the management of Posyandu and the community health workers (kader) is the responsibility of the Family Welfare Movement (PKK) of the Ministry of Home Affairs. PKK leaders are the wives of the Governor (at province level), the Bupati (at district level), the Head of Sub-district (at sub-district level), and the Village Head (at Village level), and together with the kader they are all volunteers. A newly formed ministry (2015), the Ministry of Villages, Disadvantaged Regions and Transmigration (MoV) is responsible for the planning of local development programmes, including the monitoring and empowerment of rural communities. The Government of Indonesia and UNICEF are working together under the UNICEF s current Country Programme to protect children from undernutrition and overnutrition (Country Programme Action Plan Output 1.1). One of the main focus areas of this collaboration is to enhance the capacity and commitment of provincial and district governments to effectively manage the delivery of nutrition services at scale. UNICEF is seeking a consultancy firm to undertake an Institutional and Capacity Assessment (ICA) to identify the actions needed to strengthen the multi-sector response at subnational level, and to develop the capacity to manage the delivery of nutrition-specific services at subnational level. 2. Purpose of the assignment The purpose of the Institutional Capacity Assessment (ICA) to examine the institutional arrangements and capacity of province and district government authorities to legislate, plan and manage the: Multi-sector response to address malnutrition at province and district level (Component 1) Delivery of nutrition-specific services at health facility and community level (Component 2)
3. Scope of work The consultancy firm/team will propose the analytic framework for the ICA. Some guiding principles for this analytical framework are provided below: Multi-sector vs health sector: As indicated above, the analysis has two components. Component 1 will examine broadly the nutrition governance issues concerning a multi-sector response to nutrition at province and district level through Gerakan 1000 HPK. It includes leadership to promote a multisector approach and intersectoral cooperation; structures/mechanisms for intersectoral coordination; multi-sector planning on nutrition; and monitoring of the multi-sector response. It will also examine the role of the national level, focusing on its oversight functions of Gerakan 1000 HPK and creation of an enabling environment for a multi-sector response. This component will not examine specific elements of capacity in each individual sector to deliver nutrition-sensitive interventions and services. Component 2 will explore the institutional arrangements and capacity to deliver nutrition-specific interventions at facility and community level, focusing predominantly on management capacity (planning, budgeting, implementation, monitoring and evaluation). These interventions are delivered predominantly through the health sector, under the oversight of multiple government agencies, including MoH, MoHA, MoV, and Bappenas. Government agencies and administrative levels: The assessment will focus on the government agencies/offices responsible for leading/coordinating a multi-sector response (Component 1) and those that are responsible for the technical or management oversight of nutrition-specific services at facility and community level (Component 2). The capacity assessment will be conducted at all the administrative levels: national, provincial level, district level, and sub-district level. Nutrition-specific services: The focus of Component 2 is on nutrition-specific services that target children under five years and women of reproductive age including micronutrient supplementation/fortification; infant and young child feeding; information and counselling on dietary practices; management of moderate and severe acute malnutrition; nutrition screening, assessment and surveillance; emergency preparedness and response. The majority of preventative nutrition services are delivered at community level through Posyandu (for children) and Polindes/Village Midwives (for pregnant women), under the oversight of Puskesmas and with referral to Puskesmas for higher level care, including curative nutrition services. Capacity dimensions and types: The three capacity dimensions should be taken into account: enabling environment/system, organizational and individual (see Annex 1). As appropriate, functional and technical capacities will be examined 4. Areas of enquiry: The overarching questions that this capacity assessment seeks to examine is: What are the strengths and weaknesses of the institutional arrangements and capacity to lead and manage a multi-sector response to malnutrition at province and district level, including the oversight functions at national level, and how can weaknesses be addressed? What are the strengths and weaknesses of the institutional arrangements and capacities at province and district level to manage the delivery of nutrition-specific services, and how can weaknesses be addressed? Areas of enquiry for each component will include, but not be limited to, the following: Component 1 Political commitment: Awareness and perception of provincial/district leadership on local nutrition problems and their relevance. Awareness and commitment of provincial/district leadership to Gerakan 1000 HPK. Evidence of commitment to act, including integration of nutrition targets and priorities into Medium-Term Development Plan (RPJMD) at province and district level, and alignment with the corresponding components of the national plan (RPJMN). Evidence of incentives (non-monetary, monetary) for sectors to take actions to reduce malnutrition. Public statements by leadership in support of nutrition. Parliamentary support and attention on nutrition.
Multi-sector nutrition plans: Existence of a costed multi-sector Plans of Action on Food and Nutrition at province and district level (RAD-PG), and alignment between national, province and district plans. Quality of the plan. Evidence that the RAD-PG informs annual planning across multiple sectors. Evidence that implementation of the RAD-PG is monitored regularly and evaluated. Coordination/partnerships: Existence of an institutional set-up (e.g. coordination forum) to coordinate multi-sectoral actions on nutrition with relevant stakeholders at all levels. Evidence of coordination between national, province and district levels on Gerakan 1000 HPK. Frequency and quality of dialogue on nutrition between sectors and with stakeholders groups in coordination forums. Active engagement of relevant sectors and stakeholder (government, civil society, academia, business/private, UN/donor) groups in coordination forums. Documentation and followup of actions agreed at the coordination forums. Evidence of collaborative actions between sectors and/or stakeholder groups. Mechanisms in place to foster information-sharing between partners, e.g. good practices. Human resources: Existence of focal person for nutrition within Bappeda and sectoral offices at province and district level. Availability of adequate skills (and in-service training opportunities) to support the development and oversight of multisector plans on food and nutrition. Technical guidance: Existence of adequate guidance to support provinces and districts in developing, implementing and monitoring multi-sector plans and programmes to address malnutrition. Existence of guidance to support sectors in nutrition-sensitive programming. Information skills, M&E and reporting: Existence of province/district nutrition targets. Nutrition targets reflected in sectoral strategies/plans. Mechanism for generating data on nutritional status on a regular basis (e.g. surveys, surveillance). Evidence that nutrition data and other monitoring data is being used for decision-making, and for plan and programme improvement. Documentation of lessons learned on nutrition-specific/sensitive programming, and sharing of lessons learned across districts/provinces. Clear reporting mechanism and tracking of progress and results at district level by province level, and at province level by national level. Component 2 Sectoral commitment: Awareness and perception of head of PHO/DHO on local nutrition problems and their relevance. Awareness and commitment of head of PHO/DHO to the Gerakan 1000 HPK. Evidence of commitment to act, including integration of nutrition targets and priorities into the Health Renstra at province and district level. Alignment between the RAD-PG and Health Renstra at province and district level. Institutional arrangements: Adequacy of the institutional arrangements at all administrative levels for nutrition-specific service delivery at community level and facility level. Clarity in the division of mandates and responsibilities for the delivery of community-based and facility-based nutrition services within and across administrative levels, and across government agencies (e.g. MoHA, MoHA, MoV and Bappenas), in light of the new decentralization law (UU 23/2014). Health sector plans: Availability of evidence based plans for nutrition-specific interventions. Alignment between the RAD-PG, Health Renstra and nutrition component of the province/district annual workplans (RKP/D). Availability of guidance/tools to assist provinces and districts in budgeting for the implementation (scale-up) of nutrition-specific interventions. Resource mobilization: Capacity of nutrition/health managers to understand budget process and negotiate resource allocations on nutrition and to prioritize nutrition activities. Prioritization for nutrition in the implementation of DAK (non-physical), JKN capitation payment and Village Fund (Dana Desa). Problem assessment/identification: Processes at province and district level to regularly assess/identify (i) nutrition problems and analyze underlying causes (ii) assess service coverage and bottlenecks/barriers. Evidence that data/information is being used for decision-making. Technical guidelines on nutrition services: Adequacy of existing national technical guidelines to guide nutrition service delivery at subnational level. Adequacy of the processes to propagate technical guidelines from national to province, district and sub-district level. Awareness, availability and use of technical guidelines at province and district level.
Human resources: Clarity and appropriateness of the job descriptions of nutritionists and health managers at province, district and community-health centre level. Clarity of the roles and responsibilities of health workers (e.g. doctors, midwives and nurses) on delivering nutrition services. Adequacy of staff in all key positions to support organization functions on nutrition. Opportunities for professional development, including training opportunities for functional and technical capacities. Clarity of reporting and supervision lines. Performance oversight/supervision/monitoring: Formal processes for technical oversight/supervision/monitoring of the nutrition portfolios of PHO by the MoH; DHO by the PHO; and Puskesmas by the DHO; and community-based nutrition services (Posyandu/Polindes) by Puskesmas. Coordination/partnerships at subnational level: Existence of intra-sector (within health) and multi-sector (health with other sectors) coordination to support the delivery of nutrition-specific services and integration with other programmes in the health and other sectors. Information skills, M&E and reporting: Existence of province/district nutrition targets with the heath sector. Skills and personnel to collect, collate, analyse and present data for decision making both across sectors, and within the health sector. Mechanisms in place to share knowledge/learning between national, province and district levels. Clear and regular reporting mechanism at all levels from Posyandu to national level. The Global UN Network has recently developed a Nutrition Capacity Assessment Guidance Package which may be a useful resource, particularly for Component 1. The consultancy firm/team will work in close collaboration with Bappenas, the Ministry of Home Affairs, Ministry of Village, Coordinating Ministry of Human Development and the Directorate of Community Nutrition, MoH, UNICEF and the World Bank in planning and implementing all tasks under this assignment. Where possible, officials from these ministries will be involved in primary data collection together with the consultancy firm/team. A technical advisory team, comprising government officials, academicians and other experts, will be formed to advise on the assessment design, interpretation of findings, and application of findings. In addition, the consultancy firm/team will liaise closely with other agencies working with the World Bank on a set of complementary studies that may provide important information for the capacity assessment 5. Tasks Deliverable Time-line for completion* 1. Conduct a desk review of relevant documents to summarize the existing data/information and identify data/information gaps. N/A 2. Finalize the assessment design, methods, and data collection instruments (after pretesting) for primary data collection in consultation with MoH and the technical advisory team 3. Collect data and information from the national level, selected provinces, districts and community health centres 4. Process and analyse findings, and prepare a draft report and presentation. 5. Facilitate a validation workshop to share and validate the preliminary findings 6. Finalize the capacity assessment based on feedback 7. Present the final draft capacity assessment to a forum of stakeholders from the national, province and district level. Final design, methods and instruments N/A Draft report of the ICA Presentation on preliminary findings of the ICA (Indonesian and English) Final ICA Presentation on final ICA (Indonesian and English) Time for completion of the capacity assessment is expected to be 3-4 months. We expect that the work will begin in October 2016. The consultancy agency/team of consultants are expected to propose the time-line, including start date.
4. Reporting requirements Final Report detailing the ICA will be written in English and Indonesian and be professionally proof read and publishable when handed in to UNICEF. The Report should be prepared in English initially, and the final version should cleared by UNICEF before it is translated to Indonesia. The suggested report structure is as follows, but will be confirmed in agreement with UNICEF at a later stage: 1. Contents page 2. List of abbreviations and acronyms 3. Executive Summary 4. Background/introduction 5. Methods 6. Findings Component 1 7. Findings Component 2 8. Recommendations 9. Summary All powerpoint presentations to government should be prepared in English and Indonesian 5. Methods Desk review The assessment should begin with a desk review of existing documents (including relevant legislation) and reports. This review will help to summarize what we already know about capacities at various level, and will help in the design of the final data collection tools Primary data collection methods: The assessment then adopt either a quantitative or qualitative approach or, most likely, a combination of the two. Depending on the approach selected, data collection can be through the following methods using appropriate quantitative, semi-quantitative or qualitative tools: Focus group discussions Individual interviews Surveys (self- or externally administered questionnaires) Self-assessments Case studies Workshop to validate findings Interview questionnaires or guides will need to be developed and pre-tested. In doing so, it is important to consider how the data and information will be analysed, interpreted, reported and utilised. For example, if a decision is made to use scoring and ranking, a scoring and ranking scheme should be agreed upon and prepared in advance. The questionnaires should seek to explore the existing situation, strengths and weaknesses, the desired situation, and what needs to be done to achieve it. It may also be necessary to customize the interview questionnaires or guides to different respondents. Location: Data/information will be obtained from the national level and seven provinces and districts. Seven provinces have been selected, representing provinces with a range of stunting prevalence values according to MoH 2015 surveillance data. In each Province, one district has been selected that has a stunting prevalence similar to that of the province level.
Province District Name Stunting (%) Name Stunting (%) Nusa Tenggara Timur 41.2 Sikka 40.1 Kalimantan Selatan 37.2 Tanah Laut 38.5 South Sulawesi 34.1 Pinrang 34.8 Maluku 32.3 Maluku Tenggara Barat 35.1 Papua 28.6 Kota Jayapura 27.9 Central Java 24.8 Klaten 26.1 Lampung 22.6 Lampung Utara 24.6 Participants: Different perspectives are necessary to obtain a balanced view. The assessment should involve all stakeholders and institutions that are of relevance to the assessment and future capacity development interventions. Possible participants include, but are not limited to, the following: Representatives from Bappenas, MoH, MoHA, and MoV at central/national level. Province Bappeda, Badan Pemberdayaan Masyarakat dan Pemerintah Desa (BPMPD) and Province Health Office District Bappeda, BPMPD and District Health Office Community health centre (Puskesmas) staff Health workers operating at community level (e.g village midwives), community-based workers (kader) and village government representatives (including PKK). Professional organizations Development partners (UN, donors and NGOs) 6. Qualifications UNICEF is seeking a consultancy firm to provide a team of international and national consultants. An international consultancy firm can partner with a national consultancy firm. Alternatively, a team of individual consultants can put forward a proposal. The combined team should be able to demonstrate the following qualifications, skills and experience. Master s degree in Organizational Management, Public Administration, Business Administration, Management, Development Studies, Nutrition, Social Sciences, Political Science or other related field. At least five years of relevant professional experience in similar institutional and capacity assessments and capacity development assignments. Knowledge and experience on the issue of state institutions capacity, public management and accountability, and capacity development in decentralized contexts. Knowledge of nutrition policy and programming. In-depth knowledge of the context in Indonesia (political and socio-economic landscape), Indonesia s decentralized governance system, and the health sector. Excellent analytical, research, writing and communication skills. Fluency in English/Indonesian. The roles and responsibilities of each individual consultant should be clearly defined, including the identification of the designated team leader. The team leader will be responsible for all key deliverables and will coordinate the work of all other team members during all phases of the assignment, ensuring the quality, methodology as well as timely completion of all deliverables.
Annex 1: Capacity dimensions Enabling environment or system level This level relates to the socio-economic and political context and the legislative and regulatory environment in which organizations and individuals operate. It includes both the laws and regulations which establish a body s mandate and define its responsibilities, duties, obligations and powers, and also the procedural requirements (which may also have the force of law) which determine the way in which critical functions such as participation in the budget process, recruitment or procurement are carried out. It also includes the ways in which working relationships are managed between ministries, and between central government, subnational government and quasi-governmental bodies, the arrangements for coordination of activities between different central and subnational government bodies and for partnerships between government, civil society organisations and communities Organizational This is concerned with how people are organized to enable them to play their individual roles within the institution, and includes considerations of structure, staffing, and processes and systems such as, for example, those for internal and external communication, managing work flow, strategic and business planning, budgeting and financial control, reporting and monitoring, and the recruitment, remuneration, professional development and retention of staff. It also includes the capacity to secure the critical material resources needed to support the discharge of its key functions. Structural issues include decisions about the distribution of tasks between different divisions of the organisation, nd between different levels (i.e. national, provincial and district). Measures to strengthening organizational capacities include action to improve the overall functioning and performance of an organization, and often involve changes to organizational mandates, systems, processes or priorities. Individual This focuses on the personal capabilities of the people who make up the organisation, including their knowledge, skills, experiences and attitudes, and also their actual behaviour in the work place, which will reflect both their underlying attitude to their work and the people they are serving, and also the examples they are set by their leaders. A further aspect of capacity at the individual level is the retention and transmission by experienced staff of institutional knowledge and memory, which represents a vital aspect of human capital and a foundation upon which future capability can be built. Training is only one modality through which capacities at this dimension are strengthened. Other modalities include support to knowledge sharing, networking and twinning, to mention only a few.
References/end-notes 1 Friedman J, Heywood PF, Marks G, Saaday F, Choi Y (2006).Health Sector Decentralization and Indonesia s Nutrition Programs: Opportunities and challenges. Report No. 39690-IND. Washington: World Bank. Pages 62-84. 2 GoI (2010). The Landscape Analysis. Indonesia Country Assessment. Government of Indonesia, Jakarta. 3 National Development Planning Agency/Bappenas (2014). Nutrition: Health Sector Review 2014. Jakarta: National Development Planning Agency. 4 Functional capacities are cross-cutting capacities that are relevant across various levels and are not associated with one particular sector or theme. They are the management skills and include the capacities to lead, manage, coordinate, and communicate. Technical capacities are those associated with particular areas of expertise and practice in specific sectors or themes. 5 In 2016, the World Bank commissioned assessments on nutrition service delivery in 2016 that will examine (i) supply-side readiness at primary health care and community level (staff and training, equipment and instruments, diagnostics/screening of malnutrition, medicines and commodities, information management, quality assurance mechanisms); and (ii) financing/public health management (levels, trends and distribution of nutrition funding, planning and budgeting; resource availability; external funding; public financial management).