Request for Proposal: Rotavirus Birth Dose Vaccine Assessment

CHAI Overview

The Clinton Health Access Initiative, Inc. (CHAI) is a global health organization committed to our mission of saving lives and improving health outcome in low-and middle-income countries by enabling the governments and private sector to strengthen and sustain quality health systems.  

CHAI was founded in 2002 in response to the HIV/AIDS epidemic with the goal of dramatically reducing the price of life-saving drugs and increasing access to these medicines in the countries with the highest burden of the disease. Over the following two decades, CHAI has expanded its focus. Today, along with HIV, we work in conjunction with our partners to prevent and treat infectious diseases such as COVID-19, malaria, tuberculosis, and hepatitis. Our work has also expanded into cancer, diabetes, hypertension, and other non-communicable diseases, and we work to accelerate the rollout of lifesaving vaccines, reduce maternal and child mortality, combat chronic malnutrition, and increase access to assistive technology. We are investing in horizontal approaches to strengthen health systems through programs in human resources for health, digital health, and health financing. With each new and innovative program, our strategy is grounded in maximizing sustainable impact at scale, ensuring that governments lead the solutions, that programs are designed to scale nationally, and learnings are shared globally.  

Since 2022, CHAI has served as a core partner to the Indonesian government, supporting the introduction, planning, and implementation of the Rotavirus vaccine (RV) in-country. In collaboration with key stakeholders (Expanded Program on Immunization/EPI, the Planning Unit, and BioFarma), CHAI is developing a comprehensive roadmap, operational guidance, and a national action plan to support the RV program’s transition and strengthening.  CHAI will continue to support and strengthen RV program implementation to achieve high and sustainable coverage.  Learn more about our country’s work at http://www.clintonhealthaccess.org/indonesia/. 

Background

Diarrhea remains a major cause of child mortality and morbidity in Indonesia, particularly among children under five. According to the 2023 Indonesian Health Survey, the prevalence of diarrhea is 4.9% among children under five and 3.9% in infants. [1] Rotavirus is the most common cause of severe diarrhea in under five children in Indonesia. [2] contributes to an estimated 45-61% of all cases in Indonesia. [3] Rotavirus vaccines are highly effective in reducing the burden of diarrhea in infants and young children. [4]  Expansion of rotavirus vaccines into national immunization programs worldwide has led to a 59% decrease in rotavirus hospitalizations and 36% decrease in diarrhea deaths due to rotavirus in vaccine-introducing countries, showcasing significant health impact opportunity for Indonesia. [5]

In late 2022, Indonesian Ministry of Health (MoH) initiated a phased introduction of the RV in 21 districts across 18 provinces, with a following national scale-up by Q3 2023 using an imported RV product. There is a plan to switch to a domestic product, the RV3-BB Rotavirus vaccine (produced by the local manufacturer BioFarma), which is expected to be available starting end of 2025. The RV3-BB (Bishop-Barnes) vaccine is based on naturally attenuated human neonatal strain (G3P[6]) [6] and has been shown to be immunogenic in a neonatal schedule with the first dose administered at birth. Vaccine efficacy of three doses of RV3-BB administered in a neonatal schedule was 94% at 12 months in Indonesia. [7]

Transitioning to the RV3-BB product will require a shift in the dosing schedule, with the first dose administered at birth, in contrast to the two-month starting age for the current product (Rotavac). To optimize protection and health impact, this first dose is recommended for administration within five days of birth. As the Government of Indonesia (GoI) plans for this vaccine switch, assessing the existing birth dose vaccination platform’s strengths and challenges will be vital to ensure comprehensive readiness for integrating RV3-BB into the national immunization schedule with high coverage. 

Currently, Indonesia only administers the monovalent Hepatitis B birth dose (HB0) within the first seven days of life, achieving high national coverage rates of 84%, with a breakdown of 74% within 24 hours and 10% between one until seven days. However, there are notable regional disparities in coverage, ranging from 21% to 100+% across provinces (based on administrative 2023 coverage data). 

Key challenges for birth dose coverage include location of birth delivery, system integration, community demand and acceptance, and vaccine storage and handling requirements. High coverage of the HB0 is closely associated with facility births and skilled attendance at delivery. [8] In Indonesia, 89.9% of births occur at health facilities and majority of low HB0 coverage is observed mainly in remote and rural districts with limited birth delivery either at health facility or assisted by health workers. The success of birth-dose vaccination relies on coordinated efforts between maternity and immunization units, healthcare worker’s awareness and collaboration among both private and public sectors. Anecdotal evidence of concerns about early infant vaccination, particularly regarding injectable versus oral vaccines, signals the need for strong communication efforts to build community trust. Furthermore, HB0 in Indonesia is delivered using single-dose auto-disable syringes and stored at controlled temperature, while the RV3-BB will likely require cold-chain storage and available in multi-dose vial presentation, adding complexity to operational needs related to administration, effective vaccine management, product handling, and storage. 

The recommendations will need to be tailored to RV3-BB product specifics and other programmatic considerations. For instance, cold chain consideration, defaulter tracking between the RV birth dose and subsequent doses, as well as integrated data reporting across private and public facilities may require different improvements than to HB0. Ensuring system readiness and establishing comprehensive plans will be crucial to proactively reducing confusion and errors during service delivery, while identifying and implementing necessary system adaptations to achieve high RV3-BB coverage and equity. 

Scope of Work

CHAI aims to support the GoI in planning and executing an effective rotavirus vaccine (RV) switch by conducting implementation research to identify barriers and enabling factors of the existing birth dose platform. This will help us understand the different factors that influence the country’s timeliness and coverage of birth-dose vaccines. The research will also assess specific considerations for the RV3-BB vaccine and generate key recommendations to strengthen birth dose administration in Indonesia.  

The research findings will guide EPI in identifying potential system gaps that may impact RV3-BB introduction and birth dose coverage post-switch. It will also help inform the RV3-BB vaccine switch planning and develop tailored strategies to critically strengthen the RV birth dose coverage program after switching. Nationally, the findings will provide general insights to enhance the overall performance of the existing birth dose platform (particularly for the HB0 vaccine) and facilitate the successful RV3-BB vaccine switch in 2025, ensuring a high, equitable coverage for all birth doses with minimal programmatic disruption. 

To facilitate this research, CHAI is looking to hire a local academic institution or research center to enable the conceptualization, initiation and implementation in Indonesia. 

Objectives

The primary objective of this research is to assess the key barriers and facilitators to RV birth dose vaccine acceptance by gathering insights from diverse population groups and service delivery setting, and understanding influences on the timeliness and coverage of birth dose vaccines in Indonesia, using HB0 as a reference. This research requires collaboration with key Ministry stakeholders and other counterparts to achieve the following objectives: 

a. Assess the Birth Dose Vaccine Delivery Platform

1. Evaluate current policies and practices, as well as enablers and barriers across various settings (urban vs rural, remote geography, diverse cultural background) and service modalities (private vs public, in-facility vs out-of-facility births) to adapt for RV3-BB uptake. 
2. Compare the delivery approach of HB0, first doses of OPV, and BCG and extract relevant lessons for birth dose delivery.
3. Identify effective strategies to reach out-of-facility births for timely vaccination.
4. Examine the role of village health volunteers and other community structures in identifying and referring newborns for timely birth dose vaccination.
5. Explore the coordination structures between private and public health sectors and its effectiveness as it relates to birth dose vaccines.
6. Assess cold chain situation in delivery setting both public & private health care/clinic/midwive practices – to what extent the existing RV presentation will affect its delivery & wastage when shifting the schedule to birth dose 
7. Assess cold chain situation in delivery setting both public & private health care/clinic/midwive practices – to what extent the existing RV presentation will affect its delivery & wastage when shifting the schedule to birth dose 

b. Identify Potential Demand-Side Factors Affecting RV3-BB 

1. Map current practices and perspectives for child birth delivery and birth dose vaccine, pathway to influence demand and acceptance, and key stakeholders involved
2. Explore potential challenges with oral vaccine administration at birth.
3. Assess community perceptions and demand-side barriers to birth dose vaccines. 
4. Examine demand-side barriers and limitations exist for birth dose administration (across multi-stakeholder perspectives), and potential solutions for mitigation. 

Responsibilities

The research group shall complete the following activities: 

• Develop a robust and comprehensive technical proposal outlining methodology, data collection tools (e.g., questionnaire) and detailed budget plan. 
• Conduct a desk review of existing literature and resources on the birth dose platform in Indonesia.
• Hold preliminary consultation with key stakeholders to refine study design and scope.
• Design methodology and data collection tools (questionnaire): a cross-sectional mixed-methods assessment, propose selected facilities and develop the site selection criteria at in at least across at least 8 districts (4 provinces), ensuring representation across rural, urban, remote, private, public, and in/out-of-facility birth settings and coverage level. Finalize facility selection after iterative stakeholder discussions and desk review. 
• Develop and submit the study protocol to local Ethics Committees and the Ministry of Health for administrative approval, respond to the reviewer’s feedback and ensure the protocol is finalized and approved. 
• Engage with key stakeholders and other parties such as PHO/DHO, systematically collect both quantitative and qualitative data in person to gather diverse perspectives through surveys, interviews, Focus Group Discussions (FGD), facility visits or other relevant methods as needed to gather insights from healthcare providers (vaccinators, midwives, etc.) and community members (caregivers, village health volunteers, community leaders, etc.) to understand enablers and barriers of RV birth dose. The qualitative approach recommended includes (1) health worker KAP (Knowledge Attitude Practices) surveys to identify gaps of knowledge and mapping roles and processes during antenatal visits, delivery procedures and post-natal visit; (2) health facility exit interviews with caregivers to understand experiences, and/or (3) in-dept interview with key community members or leaders to assess perceptions and practices related to birth dose vaccinations. Quantitative data might be extracted from birth registries and immunization records for additional analysis of administration timeliness. Informed consent must be obtained from all participants with no personal identifiers collected. 
• Analyze and synthesize quantitative and qualitative data to produce key findings on enablers and barriers, service delivery characteristics (facility vs out of facility), healthcare worker and community perspectives, system dynamics, leadership and governance. 
• Create a comprehensive report with infographics, data visualizations, lessons learned, and key recommendations for improving RV3-BB birth dose implementation. 
• Conduct regular coordination meeting with key stakeholders (e.g., Ministry of Health, Provincial, District Health Office, and other related stakeholders) to update progress and preliminary findings. 
• Conduct project implementation, financial management and reporting and collaborate closely with CHAI Indonesia team throughout the implementation. 
• Produce final narrative report in a publishable format to be disseminated (Full report in MS Word format, policy brief, Slide Deck in PowerPoint) once all activities are completed. 

Qualifications  

CHAI invites academic institutions and health research centers registered in Indonesia to participate in conducting this project assessing the programmatic enablers and barriers for RV3-BB birth dose vaccine introduction in Indonesia.  

Education qualifications 

• Research team member(s) with advanced degree/training in public health or health related discipline 

Skills and knowledge 

• Knowledge of immunization in Indonesia, especially for new vaccine introduction (including Rotavirus vaccine)
• Experience conducting implementation research (including quantitative and qualitative methods) on immunization programs in Indonesia 
• Experience working with government institutions e.g., Ministry of Health, Provincial or District Health Offices 
• Excellent written and oral communication skills  

Language requirements  

• Excellent knowledge of Bahasa and English

Application Requirements  

Applicants must submit three (3) pages of written proposal in English, including project timeline. The proposal should include the following information (could be included as Annex or attachment): 

1. CVs of key personnels (Principal Investigator/PI, research assistants, and field coordinators) who have: 
   • Relevant academic qualifications (Master’s/PhD in Public Health or related fields) 
   • Experienced in implementation research, immunization programs, especially new vaccine introduction, and a strong understanding of Indonesia’s health system. 
   • Proven expertise in conducting qualitative and quantitative research 
   • Strong written and oral communication skills in English and Bahasa 
   • Experience working with government institutions (e.g., Ministry of Health, PHO/DHO) is an advantage. 
2. Narrative background and objectives 
3. Methodology, sample selection, and analysis plan (survey protocol/questionnaire is optional) 
4. Implementation plan and project timeline 
5. Anticipated risks and mitigation plans 
6. Annotated budget with breakdown for honoraria, activities, and other anticipated costs 
7. Sample or examples of previous work
8. Bibliography 

Project Timeline 

The total expected duration of the assignment is within 12 months from January to December 2025. All activities and reports must be finalized and submitted within this period.  

Project Budget 

Applicants are encouraged to submit a proposal that includes a detailed activity plan and a budget, with costs not exceeding USD 150.000. The budget should include honorarium, travel, and all other expenses required to conduct the research. 

How to Apply

Please submit your proposal, including a detailed activity agenda, timeline, and budget plan by 27 November 2024 via email to indonesiaoffice@clintonhealthaccess.org and add cc to icahyani@clintonhealthaccess.org with “Proposal for RV Birth Dose Study” as the subject line. Please ensure the proposal is labelled with your institution or organization’s name, and includes all necessary documents listed in the Application Requirements section. Proposals will be evaluated based on the organization and team members’ capacities, track record, the proposed approach, and the projected implementation plan for the 12-month project duration. Only shortlisted candidates will be notified. Late or incomplete applications will not be considered. 

References

[1] Ministry of Health. Indonesian Health Profile. Jakarta; 2023

[2] Thobari, Jarir At, et al. Direct and indirect costs of acute diarrhea in children under five years of age in Indonesia: health facilities and community survey. The Lancet Regional Health–Western Pacific 19. 2022.

[3] Soenarto, Yati, et al. Burden of severe rotavirus diarrhea in Indonesia. The Journal of infectious diseases, 2009; 200, S188-S194.

[4] World Health Organization. Rotavirus vaccines: WHO position paper–July 2021. Weekly Epid Record. 2021; 96(28), 219-301; 2021.

[5] Cates, J. E., Tate, J. E., & Parashar, U. Rotavirus vaccines: progress and new developments. Expert opinion on biological therapy. 2022; 22(3), 423-432.

[6] Danchin, M., et al. Phase I trial of RV3-BB rotavirus vaccine: a human neonatal rotavirus vaccine. Vaccine 31.23. 2013; 2610-2616.

[7] Bines JE, At Thobari J, Satria CD, et al. Human neonatal rotavirus vaccine (RV3-BB) to target rotavirus from birth. N Engl J Med. 2018.

[8] Strategies to Improve Hepatitis B Birth dose Vaccination Coverage in Africa: Lessons learned from the Asia Pacific, US CDC; 2019