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Terms of reference (TOR) for Consultant to Develop a Community Health Investment Case for Uganda

 

Terms of reference (TOR) for Consultant to Develop a Community Health Investment Case for Uganda

Objectives

In view of the current Health Sector Development Plan for Uganda, the purpose of this work is to support the Ministry of Health (i) prepare a Business Case for sustained investment in community health in Uganda, and (ii) provide clear and actionable policy recommendations to enable the design and/or expansion of community health programs in Uganda.

The objective of this assignment is to yield key insight to enable Government and development partners identify and assess feasible alternative community health financing and delivery instruments and build a rigorous justification for the sustained expansion of existing and new community health programs that deliver appropriate, quality effective and efficient health care services to all Ugandans

Background

Community health is increasingly seen as an important and integral part of Uganda’s health care system Uganda has made progress towards achieving the Health Sector Development Plan with improvement of many of the health indices and outcomes. However, the country still ranks among the top 10 countries in the world with high maternal, newborn and child mortality rates (SOWM, 2015).  Uganda, with a population of 34.8 million people (Census, 2014) has a very high annual growth rate of 3.03%. This is attributed to the high total fertility rate of over six children per woman that has been sustained over the last 4 decades against the backdrop of declining mortality rates resulting from improved health care services.

 

At its core, the high burden of disease in Uganda is rooted in inequalities within the social determinants of health.  Thus, multi-sectoral action is needed to tackle the drivers of disparities contributing to preventable deaths in the country. Accessible, quality health care is essential, but much more is needed. Higher disease mortality and morbidity in some populations is often not because of a need to increase clinical encounters, but because of the environment in which we all live, our nutritional status, our quality of health prior to a disease event, access to transportation, formal education and the cultural competence of service providers.

The inadequacy of interventions against common health conditions and the inefficient use of available health resources is a challenge that must be overcome.

 

Whereas there is support from MoH to address the above challenges, there is limited prioritization of CHWs and subsequent lack of financing. With limited international funding, there is a strong need for alignment on pathways to domestic funding.

 

The community health approach can be an effective means for improving health to promote development and achieving universal health coverage. At the household level, improved knowledge and increased access to quality child health services, especially among the poor, could have far-reaching implications beyond improved child and maternal health. Improved chances of child survival free up household resources for investment in other areas, thereby reducing poverty and enhancing the quality of life. Thus, public health, human rights, and poverty alleviation concerns all point to a need to better meet the child health needs of the poor in Uganda.

Why is community health important in the context of achieving Universal Health Coverage?

Uganda prioritizes full population coverage of Uganda National Minimum Health Care Package (UNMHCP) through providing a universal entitlement to publicly financed health care services for all policy since 2000.  However, the benefits of this universal entitlement favor the richer income groups, more educated and urban dwellers.  While the country aspires to achieve Universal Health Coverage (UHC), inadequate health financing remains a huge challenge and the mechanism of health financing to deliver UHC and is addressed within the Health Financing Strategy 2015-2025.

Furthermore, health expenditures in Uganda are rising and this has significant repercussions to individuals and households in poorer population quintiles.  An estimated 1.5 million Ugandans are pushed below the poverty line due to healthcare payments (Zikusooka et al 2014).  The HSDP clearly articulates the role of strong health systems, both public and private, in reducing disease burden and as an enable to achieving UHC. However, these systems remain weak, with inequitable access to health care by a big proportion of the population and inadequate quality of services. Significant gaps remain in keys areas of the health system such as governance, service delivery including at community level, human resources for health (availability and productivity) and health financing.

 

There has been improvements nationally in addressing human resource gaps with 73 per cent of approved posts being filled. However, it is skewed in favor of specialized institutions and larger health facilities. Worse still, districts in hard to reach areas like Karamoja find it very difficult to attract and retain staff.  At 48 per cent nationally, high levels of absenteeism put’s more strain on the already overworked staff. Poor leadership/ the absence of an in-charge (42 per cent), no register book (42 per cent) and no system of granting leave (20 per cent) have been identified as contributing to absenteeism. To augment service delivery the Ministry of Health has introduced a new paid cadre - the Community Health Extension Worker (CHEWs) to bridge the gap between communities and health facilities and ensure better supervision of the Village Health Teams (VHTs). Whilst the CHEWs policy is clear, as is the case for many policies, its implementation including financing by government remains uncertain.  Basic infrastructural challenges at health facilities and communities also contribute to poor health outcomes. Approximately, 58 per cent of Health Centers (HC’s) in Uganda do not have access to electricity and this has a direct correlation to the quality of services provided.

 

The Village Health Team (VHT) program, which is the main vehicle for community-based health services and a key citizen engagement mechanism for the sector is beset by several shortcomings, including: (i) lack of proper institutionalization of the VHT strategy; (ii) inadequate supervision of the VHTs; and (iii)

reliance on volunteers. In the context of district proliferation without commensurate increases in district funding, the above challenges are more pronounced in new and remote districts with low capacity.

Strengthening and investing in a community health system will not only improve national level capacity to address the current health system bottlenecks to service delivery but also accelerate progress towards achieving the SDG’s in Uganda.

Specific Objectives

Under the overall supervision and guidance of the Ministry of Health through the department of community health, Living Goods and UNICEF, the aim of this study is twofold:

  1. Develop a business case with a clear cost-benefit analysis for sustained and increased investment in community health.

This analysis is expected to derive and clearly articulate short-, medium-, and long-term health gains from sustaining and increasing investment in community health. Building on the Health Sector Development Plan, as well as global and national level evidence for investing in community health, the analysis will identify and rigorously assess different scenarios for potential investment in community health at both macro and sector level.

Three approaches will be essentially useful:

  • Bridging existing evidence base with community health impacts on Uganda: drawing on the global evidence based and further drawing linkages to Uganda’s context build a case study that applies global lessons of community health impact on growth to Uganda. Specific themes to be considered include community human resources, community health systems, health seeking behavior and social determinants of health.

         The evidence review will include evidence from regional community health interventions including               community health extension worker’s initiatives. The analysis will assess the effectiveness in terms             of  core community health systems objectives including strengthening health prevention and                         promotion that impactfully reduce disease burden and enable the achievement of Universal Health             Coverage. As part of this, the business case will focus on community health as a critical component             of the overall health care systems.

         This component will include an analysis of existing literature on community health programs in the               East Africa region, across the continent and around the developing world that have demonstrated               impact in terms of reducing disease burden, vulnerability and equitable health care services and                strengthened resilient community, district and national health system that contribute to reduce                      disease burden. Given Uganda’s demographics and the high investment returns to child-sensitive                health services, the analysis will give proportional weight to community health programs that                        equitably and efficiently reach children and other vulnerable populations.

  • Simulation analysis to assess costs and impacts of potential community health expansion

          This modeling approach should employ household datasets like UDHS 2016, MIS and National                    Census 2014 to simulate the impact of a wide range of community health interventions on disease              burden and other health outcomes. The consultant will use a micro-simulation model that assess                the impact of alternative community health interventions on disease burden as well as the fiscal                 costs and estimates of economic efficiency brought about by community health programs and                      interventions. The analyzed policy alternatives may include community health extension worker                 programs, village health teams and other community health services delivery models and                              instruments.

  • Fiscal space analysis: Part objective of this endeavor will also involve the careful identification of Uganda’s opportunities to increase the fiscal space to address community health challenges, inequity in health care, and ultimately increased investments in community health that are realistic and compatible with the country’s macro-economic growth trajectory. Put differently, the essence of this analysis is expected to focus on how fiscal policy can be used as an instrument to address Uganda’s health care challenges, whilst alleviating the burden of disease and increasing access to health care services. This would entail looking at both expenditure and revenues as fiscal tools.

 

         2. The final objective of this initiative is to provide clear and actionable policy recommendations to                   enable the design and or expansion of community health programs that reduce disease burden                  and enable achievement of Universal Health Coverage as stipulated in the HSDP.

Deliverables: specific service / outputs to be delivered at a specific time as per stated objectives and performance / quality requirements.

The following are the proposed key tasks and deliverables

Key Tasks and Deliverables

Work output 1:  4 days

Inception report : Draft and final inception report This should provide inter alia, the understanding of the task, proposed methodology and proposed outline of the Business Case

Work output 2: 20 days

Presentation of technical Paper highlighting global and local perspectives on impact of community health at the community health TWG meeting / HPAC / MoH Senior Management Team meetings

Technical Paper  highlighting global and local perspectives on impact of community health

Work output 3: 50 days

Draft business case with a clear cost-benefit analysis for sustained and increased investment in community health plus fiscal space analysis: undertake data collection (desk reviews, interviews and other consultations) analysis and produce a Business Case report in accordance with agreed methodology and conceptual and analytical framework

Draft the Business case with proposals of workable approaches for investing in community health and also providing simulations or modeling of impacts and costs of such investments

Work output 4: 20 days

Validation Meeting

Present draft business case with its integral components of cost benefit analysis to LivingGoods and UNICEF for discussions and inputs

Final Business Case for community health in Uganda. This should provide clear and actionable policy recommendations to enable the design and or expansion of community health programs in Uganda

Policy briefs summarizing the Business Case for sustained and increased investment in community health

Work output 5: 6 days

Support advocacy meetings in Uganda to promote investment in community health-Ministry of Health, Ministry of Finance and partners

Advocacy meetings with stakeholders in Uganda conducted. Presentation material-PowerPoint especially for advocacy meetings

Total Number of Days : 100 days

Methodology

  • Secondary data review
  • Review of national statistical information (UDHS, National Census) to guide cost benefit analysis and fiscal space analysis
  • Conduct consultations with government departments and ministries especially the Ministry of Health, Ministry of Finance, Planning and Economic Development to obtain clear picture of what is appropriate in Uganda.
  • Key informant interviews: meetings with selected donors such as DFID, EU, USAID, Irish AID, the World Bank and development partner such as UNICEF, UNFPA and INGO’s like Living goods, BRAC, MSH, Pathfinder, PSI, PATH, Malaria Consortium and local NGO’s like PACE, ACCORD
  • Internal coordination workshop with Ministry of Health, Living Goods and task Team to discuss proposed actions
  • Small workshop with external stakeholders like the community health TWG
  • On-going advocacy with the Ministry of Health and her partners

Responsibilities: this section lists the activities of the assignment which will be undertaken by the partners involved

Ministry of Health with support from Living Goods and other partners (USAID, UNICEF, WHO Jphiego, PSI, Intra Health, World Vision, Amref, Pathfinder International, Path, MSH) will;

  • Ensure the objectives for the consultancy are accurately articulated to all relevant stakeholders.
  • Avail relevant background documentation to the consultant
  • Review of draft documents form the consultancy and provide feedback to the consultant
  • Pay the consultant fees and other related costs
  • Support the consultant to access key government documents and data as may be required
  • Articulate the objective of the research to stakeholders through the community health technical working group
  • Ensure ownership by government and utilize findings for advocacy purposes

Consultants responsibilities

  • Conduct all activities of the consultancy and submit quality and agreed deliverables on a timely manner
  • Provide invoices for completed work to enable Living Goods process payments

Timing: duration, i.e. beginnings and ending times for the assignment and specific timelines and milestones for individual activities, and whether or not timeframes are negotiable – and if so under what circumstance

Reporting requirements: this section lists the reporting guidelines and the reports that have to be prepared during the assignment as well as deadlines for submission; it includes requirements such as content, number of copies, who should receive the reports and whether they should be submitted electronically, in hard copy, or both

  1. Inception Report
  2. Presentation of a Technical Paper highlighting global and local perspectives on impact of community health investment at the Ministry of health Senior Management meetings, HPAC and Community health TWG
  3. Draft business case for community health in Uganda including fiscal space analysis
  4. Final Business Case for community health in Uganda in including fiscal space analysis
  5. Presentation materials-PowerPoint especially for advocacy meetings
  6. Policy briefs

Qualification requirements

Experience required:

  • Substantial international experience of community health programming
  • Knowledge of community health programs in resource constrained context within the developing world and specifically in Sub-Saharan Africa
  • Experience of developing business cases and health financing and fiscal space analysis especially in the areas of community health in Sub Saharan Africa

Expected Budget for the Consultancy and Terms of Payment

Payment of the consultant is dependent on the completion and submission of deliverables of acceptable quality.

Timing/Duration of Contract

The consultancy is expected to be completed within 100 days over a period of 3.5 months

Supervision and Administrative issue: Supervision will be provided by Health-Ministry of Health

 

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