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