Section II: Schedule of Requirements
eSourcing reference:RFP/2018/3198
Lot 1. Terms of Reference
for the feasibility study to Upgrade and Extend Services of Khmer-Soviet Friendship Hospital
(Phnom Penh, Cambodia)
1. General Background
The Khmer-Soviet Friendship Hospital (KSFH) is one of the National Referral Hospitals located in Phnom Penh, the capital city of Cambodia. It was built with contributions of both financial and human resources from the Soviet Union in the late 1950s, and initiated health service provision in the early 1960s. At present, KSFH has around 600 beds and 1002 personnel, of which 752 are government staff, including: 28 professors; 79 medical specialists; 24 medical skills, 104 medical doctors; 307 nurses; 60 midwives; 18 pharmacists; 12 dentists, and; 370 other (support) personnel.
KSFH consists of 23 in-patient departments and 1 OPD: Emergency; Medical Intensive Care Unit (ICU); Cardiology and hematology; Gastroenterology; General medicine and rheumatology; Infectious Diseases; Pulmonology; Neurology; Psychiatry; Oncology; Pediatrics; Surgical ICU; Abdominal and Thoracic surgery; Traumatology and neurology, Pediatric plastic and reconstructive surgery, Urology, Obstetrics, Gynecology, Ear Nose and Throat (E.N.T), Ophthalmology, Dermatology, Stomatology, Geriatrics, OPD and Clinical support departments such as Biomedical laboratory, Pathology, Radiology-Medical Imaging.
2. Health Service Delivery in Cambodia
In 1995 the Ministry of Health approved a new health system which aimed at improving and extending primary health care through a “District-based health system” also known as an operational district. Criteria for location of health facilities were redefined accordingly, as well as definition of a basic minimum package of health services to be delivered at each level. A district-based health system composed of three levels: the first level, the most peripheral, was made up of operational district serving approximately 100,000 - 200,000 population, and consisted of a referral hospital and a network of health centers. Each health center covered the population of 8,000 to 12,000. The second level or intermediate level was made up of a provincial hospital and provincial health department. The third or central level consisted of Ministry of Health, national institutes, national hospitals, national programs, and training institutions. As of 2006, there were eight national hospitals, 77 operational districts, 69 referral hospitals, and 972 health and 79 health posts.
Health Centres and Health Posts provide minimum-level, primary health care services mainly for rural populations. Services include initial consultations and primary diagnosis, emergency first aid, chronic disease care, maternal and child care, birth spacing advice, immunization, health education and referral.
Referral Hospitals include National, Provincial and District Referral Hospitals, classified into three levels based on the number of staff, beds, medicines, equipment and clinical activities:
- CPA-1 hospitals: no large-scale surgery (no general anesthesia), no blood bank or blood deposit, but a basic obstetric service.
- CPA-2 hospitals: emergency care services and large-scale surgery (with general anesthesia), Intensive Care Unit (ICU), and other specialized services such as blood transfusion, Ear, Nose, and Throat (ENT), ophthalmology and orthodontics services.
- CPA-3 hospitals: large-scale surgery (with general anesthesia) and more activities (more numbers of patients and activities) than a CPA-2, other various specialized services.
All national referral hospitals and most of provincial referral hospitals provide CPA-3 level services. Tertiary services are provided by 8 National Hospitals – including Khmer-Soviet Friendship Hospital (KSFH) – which are all based in Phnom Penh. KSFH is also one of two national hospitals in Cambodia that provides treatment and care for the patients suffering from a various types of cancer. It receives patients referred from every department within the hospital and from other hospitals across the country.
3. Situational Analysis
At one time, KSFH was the largest and most prominent national hospital in Cambodia. However, at present KSFH suffers from a dearth of adequate facilities, ineffectual medical equipment, and inadequate human and financial resources. With a growth rate of 1.6% in 2015, the population of Cambodia growing at a slow pace. Yet, the population in urban areas – especially in Phnom Penh – is rapidly expanding, accounting for more than 20% of the population. With rapid urbanization, the eight (8) national hospitals in Phnom Penh – 4 including KSFH – are charged with undertaking the role of tertiary referral hospitals. KSFH and the other national hospitals are thus responsible for the direct service provision of 1.6 million people in Phnom Penh, and as a referral hospital, KSFH receives patients from the provinces where local health services are inadequate; thus, on a referral basis provides services for the approximate 15 million people throughout Cambodia.
KSFH is among the busiest hospital in Cambodia. In 2016, around 215335 cases were consulted at the Outpatient Department (OPD) and 30913 patients were hospitalized within In Patient Departments (IPD).
The graph below illustrates the overall increasing trend of KSFH patients over the past five (5) years.
In the same year, the bed occupation rate at KSFH was 98.3%, with average length of stay being 7 days. Exceeding its occupancy and capacity to house and treat patients in some departments is a major hindrance to quality service provision on the part of KSFH. In an attempt to cope with the stress on placed on IPD and OPDs, arising from the steady increase of patients requiring medical treatment, KSFH established an Emergency Department in 2012.
Emergency department plays an important role to triage or refer patients to other departments. Patients referred to Medical ICU have been increased significantly from 1,625 in 2012 to nearly double in 2014 and remain high until 2016.
With the redistribution of patients from the Medical ICU (currently 25 beds) to the Emergency Department (5 beds), KSFH has struggled as the absorptive capacity of the hospital is limited due to an inadequate number of skilled and trained staff as well as equipment to handle the urgency, and number of patients suffering medical ailments.
4. Problem Analysis
I. Financing Limitations
KSFH is financed through a number of sources, including: RGC National Budget via MOH, user fees, patient health insurance claims, and claims made under Health Equity Funding designed to support the poor. Although receiving funding from numerous sources, KSFH finances itself through financial support from the government, user fees, health insurance and through the health voucher system under the Health Equity Fund designed for the poor. Annually, nearly half of all the patients visiting KSFH are impoverished and receive health services free of charge. Each year, KSFH compensates about 20 to 30 percent of its revenue to subsidize care on behalf of patients.
II. Capacity Deficit
Though staffed with nearly 900 personnel, including 35 medical specialists, 137 medical doctors, 183 nurses, 63 midwives, 12 pharmacists, and 12 dentists, limited training in advanced medical and dental practices hinder the quality of health service provision for the Cambodian population.
Due to the wide range of medical equipment donated by different sources, implying different models for the same type of device, it has been highlighted the need to update the personnel skills in the usage of the medical equipment.
III. Antiquated and/or Dearth of Medical Equipment
The quality health service provision is extremely limited due to the utilization of obsolete equipment: this is exacerbated with the ever increasing patient load as KSFH, and contributes to return-case patients, often times with more severe ailments due to deficient diagnosis and treatment upon initial visits. Furthermore, with the majority of the hospital equipment being outdated, the incidence rate of malfunction exponentially increases the probability for misdiagnosis and/or accident. As an example, the oxygen system has been considered insufficient for the current needs of the Hospital.
IV. Infrastructure Decay and Absence of Hospital Waste Water Management System
As the “…lifespan of many types of infrastructure can be 50 to 100 years [.][1]” the viability of KSFH is already in the latter years of its lifecycle. Consequently, KSFH has been affected by a number of infrastructure related issues that has increased risk for both KSFH personnel, as well as health service recipients. Some of the most glaring infrastructure issues include: deteriorating physical integrity of buildings due to flooding; unsafe electrical systems arising from lack of maintenance and/or upgrades, and; absence of a Hospital Wastewater Treatment System.
The Hospital Management has also deemed necessary the construction of a new Trauma Centre, with an 80-bed capacity, in order to serve the demand of this kind of medical services. Furthermore, additional Intensive Care and Emergency Units have been highlighted as necessary.
5. Objectives and scope
In order to consolidate various existing plans into an overall master plan, UNOPS will engage an international consultancy firm to develop the needs assessment of the hospital. The firm will support the Management of the KSFH and national authorities in the assessment, planning and coordination of the scope of services at the hospital in order to ensure equal access to improved quality care for all population groups.
The feasibility study will analyze areas such as infrastructure, staffing, medical equipment and medical needs in the Hospital, among others.
The following are the objectives and scope of the assignment:
1-Description of the health system, at national and local level
-Mapping of the existing hospitals: population serviced, medical services delivered, etc.
-Statistical analysis of available data: (e.g.: Geographic Data, Metrological data, Disease patterns, Existing facilities)
-Needs assessment for medical services and projection by age, sex and needs in terms of medical services.
-Legal framework and national regulations for design and construction of hospitals
2-Gap identification between the population needs and medical services offer
-Quantify the gap between the actual population needs and medical services offer: type of residents, affordability status, coverage area, beliefs, attitude and culture.
-Human Resources analysis
-Adaptation and improvement of the existing national standards for hospital construction
-Recommendations for the type of services and size that should be included in the hospital as per the results found (e.g.: Preventive, curative, rehabilitation, general care, special care)
-Identification and assessment of possible options and associated financial envelop
3-Program of the hospital (selected options)
-Schematic/Conceptual architectural designs/plans
-
-Dimension of new services (# beds #rooms / service)
-Land tenure and administrative steps for construction authorization
-Basic architectural and technical specifications for the building (room surface, ventilation, waste management, clean/dirty flux, circulation, link between services, etc.)
-Basic specifications of medical equipment needed:
- Minimum equipment required after expansion
- Recommended equipment after expansion
- Availability of maintenance department within the hospital
- Medical Equipment suppliers in country and post sales service availability.
- Power requirements of specific equipment
- Additional training required for specific medical equipment needed:
-Assessment of the necessary works to be undertaken for the functioning of the health utility (water, electricity, sewage, access road, waste management, incinerator, etc.)
4-Investment’ sustainability
-Assessment of human resources (type and #) to run the facility and associated cost
-Minimum skills and qualification levels and training to be provided, through:
- Number of existing staff and specialization areas
- Number of required physicians after expansion
- Funding availability from GoM for incorporation of new staff
- Survey to determine gaps in medical knowledge per discipline
-Retention mechanisms of trained staffs
5-Roadmap/next steps
-Identification and assessment of possible options for expansion/renovation and associated financial envelop
-Next steps to be taken in any option proposed with indicative timeline
6. Profile of the consulting firm:
- Experience in conducting feasibility studies for health sector is a pre-requisite;
- Experience of working in humanitarian, development or other public sector work, particularly in Southeast Asia region and/or Greater Mekong Sub-region is highly desirable;
- Proven strong writing and communication skills including demonstrated experience writing research articles and/or master plans and familiarity with gender and conflict sensitive analysis;
- Proven ability to manage relationships with partners, including government, UN and the private sector;
- The firm must be thoroughly proficient in written and spoken English;
- Knowledge of the UN system and familiarity with UNOPS procedures is an advantage;
- Previous experience of working with international organizations of the UN system is an asset;
- Understanding of the Cambodian context.
7. Timeframe
The consultancy company shall complete the feasibility study in a period of months 3 months as of the award of the contract
UNOPS will facilitate Visa procedures, if needed, for the deployment of experts to Cambodia and any authorizations required to access Khmer-Soviet Friendship Hospital.
The consultancy company shall plan for 1 month mobilization period (not included in the 3 month duration of the assignment).
8. Costing
The consultancy company is responsible for all the traveling, logistics to fly in and out Cambodia, accommodation in Phnom Penh, meals and any other matter related to the preparation of the feasibility study, if required.
Lot 2. Terms of Reference
for the feasibility study to Upgrade and Extend Services of the Mittaphab (Friendship) Hospital (Vientiane, Lao PDR)
1. GeneralBackground
Mittaphab hospital is one of four central hospitals in Lao People’s Democratic Republic, and specializes in a number of key areas including, but not limited to, neurosurgery orthopedics and blood replacement transfusion.
Since 2009, Mittaphab Hospital has undergone several renovations accompanied by the procurement and installation of new equipment to replace obsolete equipment and facilities. This has included the introduction of Laos' first Magnetic Resonance Imaging (MRI) for service; the construction of the Emergency Unit as well as a resuscitation building for dialysis and artificial kidney treatment; refurbishment of the neurosurgery building; refurbishment of an isolation building for communicable diseases; renewal of traumatology center and the teeth-chin- face operation unit with modern technologies (including new medical equipment and capacity building for medical specialists); renovation of virology treatment centre; procurement of various medical equipment to increase effectiveness of treatments and value-for-money; and construction of a wastewater treatment system for the hospital, currently showing some deficiencies in its functioning.
2. Health Service Delivery in Lao PDR
The health situation in Lao PDR has been progressively improving during the last two decades, but health indicators still remain relatively low in a regional perspective and the health care system is insufficiently developed at all levels, particularly with regards to primary health care. There is evident geographically unequal distribution of health care services and health workers with a concentration of skilled professionals in the urban areas, and central hospitals that are over-utilized.
Since 2000, the government of Lao PDR has been introducing policies and strategies to implement health sector reforms aimed at achieving the Millennium Development Goals, improving health financing and systems, setting standards that would conform to international ones, and strengthening sector coordination. The government’s Eighth National Socio-Economic Development Plan (2016–2020), reflected its commitment to improve human development outcomes, among which universal access to quality health care services is specifically stated. Moreover, a Health Sector Reform Strategy (2013-2025) has been recently approved by the Government. To make health services financially accessible to the poor, the government, with the support of development partners, has financed Health Equity Fund (HEF) schemes. The government is also implementing free delivery of maternal, neonatal, and child health care (MNCH). However, those schemes operate under different implementation, financial management and monitoring mechanisms, having limited coverage.
Government spending on health has been low (about 4%) for most of the last two decades but is gradually growing after the National Assembly in 2011 decided that the government expenditure should increase to 9%. In 2013, the new Decree 349 was endorsed to replace the Decree 52, which aimed to provide fair and equal access of health care for all Lao citizens, and to enhance the quality of services by introducing drug revolving funds and a cost recovery system with user fees.
The delivery of public health services is primarily implemented through a network of health centres at district, provincial and central hospitals. Health services in the Lao PDR are provided through 4 central general hospitals and 3 specialist hospitals in the capital, 16 regional and provincial hospitals and approximately 130 district hospitals, 860 health centres, and around 5239 village mobile stations. As of 2011, the number of hospital beds per 1000 population was 0.8, which represents a declining trend in comparison to the beginning of 2000s. Data on beds in private hospitals and clinics are not available. According to data from 2010, there are 222 authorized private outpatient clinics in the country. Among them, 96 are in Vientiane, 34 in Savannakhet and 23 in Xiengkhuang. Another 647 have applied for authorization. A limited number of public–private partnerships have been reported, such as international clinics serving Lao and foreign patients at Mahosoth Hospital and Setthathirath Hospital. Besides this, there has been very little investment in mental health facilities to meet the demand of the country. Also, according to recent ASEAN Agreements, the health sector is meant to be open to foreign investment. In parallel, MoH is drafting a new national licensing system to allow practitioners to open clinics.
The private health sector has been expanding; as of 2013 there have been over 2132 private pharmacies, 600 traditional medicine practitioners and about 222 private clinics.
The provinces lack information on skills, health workforce development and deployment plans. There is no functioning regulatory system for licensing and registration of health professionals. The development budget, including all budgets from aid-financed projects, is not disaggregated, and there is no institutionalized system of national health accounts. Better financial management is needed to ensure system transparency and accountability.