For the Consultancy Services of the International Institution

Purpose: Technical Assistance to the Ministry of Health and Social Protection (MoHSP) in defining and costing the minimum Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) Service Package

Level of consultancy: International Institution

Duration of contract: 1July 2016 – 30April 2017

Location: Dushanbe, Tajikistan

Closing date: by 17:00 (GMT +05:00) on 13June 2016

TERMS OF REFERENCE

  1. BACKGROUND AND JUSTIFICATION

Maternal and Child Health (MCH)remains the priority of the Government of Tajikistan as outlined in major strategy documents pertaining to improving the health status of the population. In the past decade, under-five mortality rate in Tajikistan has dropped from 93 per 1000 live births in 2000 to 45 in 2015 (UN IGME, 2015), but it fell short of the MDG4 (Reduce Child Mortality by two-thirds, between 1990 and 2015) target of 36. Neonatal mortality is stagnating at 22 per 1,000 live births. Top three causes of neonatal mortality include birth asphyxia, respiratory distress of newborn, and birth trauma, some of which suggest links with poor quality of skilled care at birth. This underscores the importance of improving a coverage of ‘quality’ ‘continuum of care’ for reproductive, maternal, neonatal and child health (RMNCH). According to the Maternal Mortality Estimation Inter-Agency Group (MMEIG) estimate, Maternal Mortality ratio (MMR) is 32 per 100,000 live births in 2015. While this represents over 70% reduction from 107 per 100,000 live births in 1990, it remains high. The key causes of maternal mortality in Tajikistan are related to poor quality coverage of antenatal care, inadequate facility-based health services during delivery, compounded by difficult geographical access particularly in rural areas and capacity constraints of service providers. Inequities are also present in access to and use of maternal health services. According to the 2012 Demographic Health Survey (DHS), only 58.5% of women from the poorest quintile of households delivered at health care facilities, compared with 91.2% among the richest quintile.

Government spending on health, though increasing, is still well below financing requirements and compares poorly to other countries in the region at 2.1% of GDP in 2013[1], which is compensated by high levels of out-of-pocket expenditure. This, along with uneven geographical distribution of public health resources, results in persistent financial barriers for the poor to access health care, and raises concerns about equity across regions and income groups. Substantial shortfalls in state funding also translate into fragile health system, and quality of care remains a challenge. With a view to addressing this bottleneck, a number of health financing reforms are underway in Tajikistan, including the introduction of formal co-payment for diagnostic services (Decree No 600), a basic benefits package (BBP), a partial capitation in primary health care (PHC), the concept of a case-based hospital payment system, and results-based financing in primary health care. BBP has been piloted since 2004 with a gradual scale-up of geographical coverage. The Government Decree on the Strategic Plan for further reform of health financing in the Republic of Tajikistan for 2015-2018 and the health financing roadmap[2] envisage the BBP to be rolled-out to the entire population, with per capita financing and full capitated rate payment system. There are some discrepancies between BBP with co-payments and the Decree No 600 with fee-for-service, which need to be reconciled. Partial per-capital financing of PHCwas piloted in 2005-6 and the joint decree 68-7 by the MoHSP and Ministry of Finance (MoF) in 2009 stipulated that at least 40% of the funds from the local health budgets should be allocated to PHC. The 2013 MoHSP and MoF joint decrees stipulated that full capitation be tested in two rayons of Sogd Oblast starting April 2013 and further rollout of the full capitation to all of Sogd Oblast starting July 2013. The PHC full capitated rate payment system was further refined for national scale-up with technical assistance from World Bank, and the Government approved the Resolution No. 827 “On issues of introduction of per-capita financing in PHC facilities” on 31 December 2015.

In moving forward, especially to ensure a greater share for critical RMNCAH interventions in public expenditure, efficiency gains and an easing of financial barriers for the most disadvantaged to access quality care, lack of clearly defined service package by different facilities at different levels has been identified as a major bottleneck. The existing government documents such as BBP and clinical protocols do not list the specific interventions to be provided by different service providers or facilities (medical houses, rural health centres, district and city health centres (policlinics), district and city hospitals, maternity, children and specialised hospitals relevant to RMNCAH) and at home (outreach services). This gap was also pointed out during the round table discussion on per capita financing implementation in PHC facilities held in January 2016 - “The existing PHC system in Tajikistan comprises a wide range of outpatient services and service-providing facilities. Various government documents describe in broad terms the preventive, curative and specialized outpatient services to be provided within the PHC system. However, a precise listing of the specific medical interventions to be provided at each type of the PHC facilities is largely absent.Without the service lists specified clearly, the basis for the existing staffing norms remains largely unclear. Decision-making on the requirements for appropriate capacity/skill-mix of health providers (staffing norm to approve) and other input becomes more logical and objective if the service package for each facility type (list of PHC services to be dispensed) is established in a clear-cut manner first.This will also help to arrive at more accurate per capita rates and thereby allow to maintain a better logical balance between the amount of capitated funds being provided to the PHC providers and the package of services (the list of specific health services) they must dispense to the attached populations” (Subrata Routh and AbdugafforNurov, World Bank consultants). The consultants went on to call for the MoHSP’s urgent action to develop a clear-cut listing of the specific interventions (service package) to be provided at each type of the PHC facilities.

  1. OBJECTIVES

The proposed consultancy aims to assist the MoHSP in defining and costing an essential package of services in the area of RMNCAH to be offered at the following levels of health facilities within the health system and the interlinkages between them.

  • Health Houses
  • Rural Health Centre
  • District Health Centre (Policlinics)
  • City Health Centers (Policlinics)
  • Rural Hospitals
  • Central District Hospitals
  • City Hospitals
  • Oblast and City Maternity Hospitals
  • Children Hospitals
  • Oblast Hospitals
  • Specialized Hospitals relevant to RMNCAH (TB, Infectious disease, etc.)
  • Outreach services through home visit

By concentrating scarce resources on the essential services which provide the best 'value for money', this exercise, in turn, is expected to achieve improved efficiency, equity, accountability, and altogether more effective RMNCAH care.

  1. MAJOR TASKS TO BE ACCOMPLISHED:

An international consultant will be responsible for the assignments as stipulated below:

  1. Review policy documents guiding the country’s RMNCAH priorities, including National Health Strategy 2010-2020, BBP, Decree 600, and RMNCAH-related laws, orders[3], policies, strategies, clinical protocols/guidelines, and job descriptions of the different health workers. Review other relevant assessment and review reports describing the RMNCAH situation, including disease burden and unmet needs of the population, as well as health system in Tajikistan. This should also include documents related to ongoing rationalization efforts. Tajikistan Health Sector Master Plan 2010 reports are among the important sources of information, which provides detailed description of health system structure per district.
  2. Review the budgetary data, reports on the Marginal Budgeting for Bottlenecks (MBB) analysis, National Health Account and Reproductive, Maternal and Child Health Sub-Account, and other relevant costing studies,expenditure data at various levels of the MoHSP, and health indicators data to assess both the priority setting and the budget allocation process by the MoHSP.
  3. Based on the information gathered from the desk review, support MoHSP in identifying the priority interventions (essential service package) in the area of RMNCAH by different facilities at different levels, taking into account the following:
  • High impact, cost effective, evidence–based services that can be delivered successfully in Tajikistan context
  • Diseases or health conditions that have heavy burden on Tajikistan population, considering the effect on individuals as well as society
  • Equity in ensuring that critical health services are provided to all, especially the poor
  • Sustainability of service provision in the long term – affordability and feasibility based on the human and financial resources available.
  • Inter-relation between tiers of service to ensure continuum of care – clearly defined referral chains
  • Relevance to and consistency with the existing policy, guidelines, and commitments, including BBP
  1. Review the available costing methods and choose/adapt one that is most appropriate in Tajikistan context. Conduct a costing exercise based on both the real population needs and the current service utilization pattern, taking into account staffing, supplies, equipment, and other resources that are required for delivery of the identified priority interventions (a several options) with due attention to continuum of care.
  2. Facilitate a consultation workshop where several options of essential RMNCAH service package with cost simulation will be presented to broad range of relevant stakeholders. Facilitate discussions to reach the consensus and final political decision concerning the essential RMNCAH service package to be offered at different facilities.
  3. Producea document outlining: i) the essential RMNCAH service package broken down by different level of facilities; and ii) costing of the essential RMNCAH service package, including methodologies, for the government approval.
  4. Submit the final report to UNICEF, describing the process and recommendations, including on the additional services that could be included in near future (broken down by different level of facilities) to make the aspirational essential RMNCAH service package.

As this exercise forms an important part of the health sector reform in Tajikistan, which is high on MoHSP agenda, throughout the consultancy process, the contracted international institution should work very closely with the MoHSP senior officials and managers responsible for maternal and child health service delivery as well as financing and resource components of National Health Strategy 2010-2020 implementation.

  1. METHODOLOGY:

The assignment should be performed through continuous consultative process to allow the government’s decision making based on the combination of technical, political and social considerations. As such, in addition to the desk review of existing policies/laws, strategies, programmes with budgets, situation analyses, surveys,and studies, the consultants are expected to hold a number of interviews continually with government officials both at national and sub-national levels (MoHSP, MoF, local authorities),health service providers, as well as other relevant stakeholdersand partners (World Bank, EU, SDC, USAID, WHO, UNFPA, KfW, and GIZ, etc.). They should also conduct field visits to observe service provision at district level.

  1. DELIVERABLES and TIME FRAME

№ / Deliverables / Timeframe
Inception report, elaborating the overall methodologyand the work plan in order to complete the assignment / 31 July 2016
Draft proposed list of essential RMNCAH service package by level of health facilities, with level of priority and rationale for inclusion / 15September 2016
Costing methodology and costing questions that need to be addressed / 15 September 2016
Consultation workshop on the initial proposed list of essential RMNCAH service package by level of health facilities and costing methodology / 1October 2016
Costing of the essential RMNCAH service package with engagement of MoHSP and MoF experts at national and sub-national levels / 31December2016
Validation workshop on the costing of the essential RMNCAH service package / 15 January 2017
Round table discussion on essential RMNCAH service package and costing (for consensus building) / 15 February2017
Submission and UNICEF approval of the following documents:
-RMNCAH service package vol.1 Details of the package
-RMNCAH service package vol.2 Costing
-Final report to UNICEF, summarizing the process and outcomes of the assignment as well as a set of recommendations and follow up actions / 30April 2017

The payment will be madein three phases: 1) 20% upon inception report; 2) 20% upon completion of the consultation workshop and provision of draft proposed essential service package and costing methodology; and 3) 60% upon submission of the RMNCAH service package vol.1 Details, RMNCAH service package vol.2 Costing and Final report.

  1. ETHICAL CONSIDERATIONS

Adequate measures should be taken to ensure that the process responds to quality and ethical requirements. The contracted international institution should be sensitive to beliefs, manners and customs and act with integrity and honesty in their relationships with all stakeholders.

  1. ELIGIBILITY CRITERIA

All the interested international institutions with prior experience in defining and costing health servicesare invited to submit technical and financial proposals.

Required qualifications

  • Extensive experience (at least 8 years) in the area ofPublic Health and Health Financing / Public Finance Management;
  • Relevant consultancy experience with international/UN organizations in the field of health financing / Public Finance Management (esp. costing of essential health service package), RMNCAH, health systems management, planning and programme development. Experiences in CEE/CIS countries is preferable. Prior experiences with UNICEF would be an advantage.
  • The team members should be fluent in spoken and written English. Knowledge of Russian/Tajik will be an added advantage.
  • Excellent facilitation, communication, analytical and report writing skills;
  1. REPORTING ARRANGEMENTS

The contracted international institution will report to Health Specialist of UNICEF Tajikistan, under the overall supervision of Chief, Health and Nutrition of UNICEF Tajikistan. The international institution should work collaboratively and communicate clearly with UNICEF, MoHSP, MoFand other key stakeholders. This includes:

  • Working in a collaborative, respectful, and sensitive manner
  • Maintaining clear, ongoing communication with UNICEF team throughout the consultancy period
  • Participating in regular team meetings with the key stakeholders

The performance evaluation shall be completed based on the timely submission of the deliverables, accuracy and quality of the deliverables.

1

[1] accessed on 11 April 2016

[2]Health Financing Roadmap:Moving Towards Universal Health Coverage in theRepublic of Tajikistan. Sheila O’Dougherty, Olga Zues (WHO Consultants),Baktygul Akkazieva (WHO CO TJK). Dushanbe, 2014.

[3]This includes the documents describing the proposed referral mechanism for RMNCAH services such as: MoHSP order #443 as of 07/0/2012 on “Provision of hospital care to pregnant, mothers and newborns at maternity units of level 1 and 2”; MoHSP order #444 as of 07/09/2012 on “Approval of regulation on prenatal care centers”; and MoHSP regulation on provision of hospital care to pregnant, mothers and newborns at maternity units of level 1 and 2.